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Release of Information Authorization

Release of Information Authorization to Release Information From/To A Third Party With SpringSource Psychological Services (“ROI”)

Please note, all fields are required for this form to be submitted.

I hereby authorize SpringSource Psychological Center, PLLC to:

Release information to and obtain information from the below-named person or institution (this should be someone like a medical doctor, psychiatrist, dietitian, or emergency contact, etc.):

    I have had explained to me and fully understand this request/authorization to release/obtain records and information, including the nature of the records, their contents, and the likely consequences and implications of their release. This request is entirely voluntary on my part. I understand that I may take back this consent at any time, except to the extent that action based on this consent has already been taken.
    This entry acts as a client signature.
    This form has been modified from The Paper Office. Copyright 2008 by Edward L. Zuckerman.

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      Therapy Tribe Psychology Today

      We provide in-person therapy in Northbrook and Chicago, with telehealth therapy available throughout Illinois.
       
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