Authorization Form

"*" indicates required fields

Client Name*

First Last

Date of Birth*

MM slash DD slash YYYY

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Duration of Exchange

This release of information is valid for the following time period.

Date From

MM slash DD slash YYYY

Date To

MM slash DD slash YYYY

Parties of Exchange

In this section, please identify the person (or people) authorized to speak to Jeanne Holverstott, MS.

I authorize the following person to exchange information with Jeanne Holverstott, MS

Prefix First Middle Last Suffix

Address

Street Address Address Line 2 City State ZIP Code

Phone

Content of Exchange

In this section, please identify the information Jeanne Holverstott, MS, is authorized to exchange with above listed “Parties of Exchange”.

I authorize Jeanne Holverstott, MS to provide information with Parties of Exchange.

All Records

Treatment Goals/Progress

Payment for Treatment

Email Correspondence Related to Client

Scheduling/Canceling Appointments

Testing Results and Report

Other

If Other, please specify

Purpose of Exchange

In this section, please identify the specific purpose Jeanne Holverstott, MS, is authorized to communicate with the above listed “Parties of Exchange”.

Purpose of information to be exchanged

Phone or email consultation with psychiatrist

Phone or email consultation with parents

Phone or email consultation with primary care physician

Provide Scheduling Information

Provide Financial Information

Other

If Other, please specify

Signature

Signature*

Name

This field is for validation purposes and should be left unchanged.

Jeanne Holverstott, MS

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Contact Jeanne

"*" indicates required fields

Name*

First Last

Email Address*

Message

Phone

This field is for validation purposes and should be left unchanged.