form-authorization-consenting-to-release-of-information

AUTHORIZATION CONSENTING TO RELEASE OF INFORMATION

I authorize Teresa Lauer, LCPC, LMHC to discuss (verbally or in writing) anything that has been brought up during our assessment, consultation, psychotherapy or evaluation with any person(s) or staff of clinic, office, agency, or institution(s) named below and relevant information from them pertaining to this assessment.

Contact Us

New Field:

Name:

Email:

Phone:

#1 Name of Person for Other Reporting Form

#1 Relationship

#1 Email

#2 Name of Person for Other Reporting Form

#2 Relationship

#2 Email

# 3 Name for "Other Reporting" Form Submission

# 3 Relationship

#3 Email

For the following reason(s):

Completion of "Other Reporting" form for Adult ADHD Assessment

Consultation/Psychotherapy

Coaching

Evaluation

I may revoke consent text

I may revoke this consent at any time. This consent is in effect for five years from the date of the last session, unless revoked in writing earlier or renewed. This consent is also subject to all conditions outlined in the Adult ADHD Informed Consent Form.

Initials Checkbox

I understand that my initials on this form will serve as authorization. I also understand that I will be required to submit a printed copy of this form with my signature.

Initials

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Teresa Lauer, LCPC, LMHC

1180 N. Town Center Drive, Suite 100

Las Vegas, NV 89144

The Canyons at Summerlin

Conveniently located near Summerlin Hospital

Teresa Marie Lauer, LCPC, LMHC