Consent to Release / Exchange of Information

Either complete the online form below or click here to download a PDF of this form, print, sign and bring into the office.

I hereby give my permission for a mutual exchange of information between Rebecca K. Lowry, LCMHC, and
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Fax*
concerning the treatment of (including medical, psychological, and/or education records)
Client's Name*
First Last
Date of Birth:*
Month
Day
Year
Address*
Street Address Address Line 2 City State ZIP Code
Phone
For the purpose of...*
I understand that I may revoke this consent at any time except to the extent that action has already been taken in reliance on it, and, if not revoked sooner in writing, this consent will expire 365 days from the day signed. I understand that I have the right to receive a copy of this consent.

Release or transfer of the above information to any other person or organization is prohibited without an additional written consent authorizing such a transfer.
Client Name*
please type full name
Client Signature*
Parent/Guardian Name
please type full name
Parent/Guardian Signature
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Date*
Month
Day
Year