Client Release of Information | Wendt Center for Loss & Healing

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

Authorization to Release/Receive Information

You are filling out this form in order to allow the Wendt Center to provide information about your services to another individual, organization, or entity. Please carefully review each option, and if you have any questions about what they mean please check with your clinician or email forms@wendtcenter.org for support.

1. The Wendt Center for Loss and Healing has my permission to:

Select all that apply.(Required)

Send To

Receive From

Verbally, telephonically, or electronically discuss with

Agency/Individual:(Required)

Please enter the name of the person or organization you would like us to provide information to or receive information from.

Address

Please input the address of the person or organization if you are able.

Street Address Address Line 2 City State ZIP Code

Phone

Please input the phone number of the person or organization if you are able.

Fax

Please input the fax number of the person or organization if you are able.

Please input the email of the person or organization if you are able.

2. Items covered by this release include:

Select at least one:(Required)

Acknowledgement of receipt of services

Complete Client Record

Program Record Only

Other

Program Records(Required)

If you would like us only to share records from certain programs or types of services you received, please select them below:

Individual Therapy

Group Therapy

Resilient Scholars Project

Other Records(Required)

If you selected Other above, please specify what records you would like us to send or receive.

3. This authorization is valid:

Select below:(Required)

Until a date I specify

For 90 days

Until conditions are met

Until revoked by client

Date(Required)

If you selected for this authorization to be valid until a specific date, enter the date here (not to exceed one year):

Conditions(Required)

If you selected for this authorization to be valid until certain conditions are met, please describe below the conditions. For example, you could say “until I turn 21” or “until I have my initial assessment”.

4. Reason for release

Please describe the reason you are authorizing us to communicate with another person/organization.(Required)

Signature

I understand I can revoke (withdraw) this authorization at any time by submitting a request in writing to program staff or to forms@wendtcenter.org. The revocation will become effective on the date it is received by Wendt Center staff, and does not apply to information that has already been used or disclosed through this authorization. The Wendt Center may not condition treatment, payment, or enrollment or eligibility for benefits based on whether I sign this authorization. I understand that if the person or organizations I authorize to receive and/or use my health information are not subject to federal or state privacy laws, this information may no longer be protected and could be disclosed.

Client/Participant Legal Name(Required)

First Last

Client/Participant Date of Birth(Required)

Signature(Required)

If signed by Parent/Caregiver/Legal Guardian:

Guardian Name

First Last

Relationship to Client/Participant

Send Form

Please select the name of your therapist:(Required)

If you are currently in contact with your therapist, please make sure to select their name so they receive a copy of the form. If you are a previous or prospective client, or do not see your therapist’s name on the list, please select “Administrator” and we will locate your record for you.

To receive a PDF copy of your signed form, please enter an email address.