Release of Information

PERSONAL INFORMATION

Name*

Home Phone*

Cell Phone*

Email Address*

I authorize

Actions To send the following information to
To receive the following information from

Authorized Personnel

Name

Address

Name

Address

Name

Address

Items to be released (check all that apply) Academic testing results
Case notes
Medical reports
Progress reports
Summary reports
Intelligence testing results
Behavior program
Personality profiles
Vocational testing results
Entire record
Psychological reports
Service plans

Other

The above information will be used for the following purposes: Planning appropriate treatment or program
Continuing appropriate treatment or program
Case review
Determining eligibility for benefits or program
Updating files

Other

I understand that I may revoke this consent at any time by providing written notice, and after one year this consent automatically expires. I have been informed what information will be given, its purpose, and who will receive the information.

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(703) 530-9800

Our broad spectrum of services include, but are not limited to:

Treatment Services

Alcohol and Drug Services
Anger Management
Drug Court Treatment
DUI/DWI Evaluation/Assessments
Immigration Psychological Evaluations
Parent Education Groups (H.O.P.E.)
Shoplifting Intervention Services
Supervised Parent Visitation

Assessments

Chemical Dependency Evaluations
Alcohol and Drug Addiction Assessments
DWI/DUI Court-Ordered Chemical Use Assessments
Anger Management Assessments
Immigration Psychological Evaluations

Caring, Confidential, and Professional Counseling for Northern Virginia

Court Related DUI Evaluations and Drug and Alcohol Evaluations

HOPE, A State Approved Parent Education Class

Shoplifting Interventions for Adults and Juveniles

Release of Information