4. AUTHORIZATION FOR RELEASE OF INFORMATION

I (We) authorize    (Facility/Provider)          (Address) to release

from the clinical record of          

          (Name of client/recipient of mental health services)                      (Date of birth)

to POSITIVE GROWTH, INC. 945 North Indian Creek, Clarkston, Georgia 30021

for the purposes of facilitating counseling/consultation, and/or conducting an evaluation. I understand that I may revoke this consent at any time. This authorization is valid until .  (Date)

It has been explained to me that if I refuse to consent to this release of information, the following are the consequences (specify, if any):    no information released and/or 

A copy of this release shall have the same force and effect as the original.

(Client Signature 12 yrs. or older)
Date
(Parent/Guardian Signature)
Date
(Witness)
Date
(Relationship)

NOTICE TO RECEIVING FACILITY/THERAPIST: You may not re-disclose any of this information unless the person who consented to this disclosure specifically consents to such re-disclosure.


6. School Authorization Release of Information

All the information I hereby authorize to be obtained will be withheld in a confidential fashion and WILL NOT be released to another recipient without a written consent by the Individual’s legal guardian. The information obtained is for treatment purposes only. This release is protected under the State and Federal Confidentiality Regulations copy is valid in lieu of the original.

I understand that I authorize the release & obtaining of above checked information. The period necessary to complete all transactions on accounts related to Positive Growth, Inc. services are effective immediately (today’s date) . This consent will expire twelve months after the date signed. I understand that this does not affect information released prior to this date. This release can be revoked at any time.

(Client Signature 12 yrs. or older)
(Date)
(Parent/Guardian Signature)
(Date)
(Witness)
(Date)
(Relationship)