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About
About
Statement of Faith
FAQ
Counselors
Cost
Partners
Impact
More
This vs. That
Consult the Counselor
Rode Leadership
Events
Articles
Careers
Contact
Emergency Resources
Book a Session
RELEASE OF INFORMATION
Client Information
Name
(Required)
First
Last
Date of Birth
(Required)
Phone
(Required)
Counselor
Who has the information to be released?
Name
(Required)
First
Last
Email
(Required)
Receiving Party
Who will the information be released to?
Name
(Required)
First
Last
Relationship to Client
(Required)
Email
(Required)
Phone
(Required)
Information to Be Released
What will Be Released?
(Required)
Intake summary
Intake notes
Counselor insights and/or recommendations
Progress notes, and treatment or closing summary
Other
List Other
Purpose of Release
Why is information being released?
(Required)
Legal Purposes*
Coordination of care with another counselor
Communication with a pastor or ministry leader
Consultation with other mental health provider
Transfer of care to another counselor
Other
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*Before information is released for legal purposes, the counselor must consult with Anchored Virtual's Director of Operations and President/CEO.
Duration of Consent
Please select all of the following
Duration
(Required)
I consent to a one-time release of information.
I consent to ongoing sharing of information between my Anchored Virtual counselor and the following people______________________________
I consent to the release of information until the completion of counseling or until the following date
Please list names of people
(Required)
Date
Please select date you agree to share your information until. You can also leave this field blank.
Signatures
Signature of Client
(Required)
Today's Date
(Required)
Signature of Provider
Today's Date
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