Authorization to Obtain and Release Information

Authorization to Obtain and Release Information

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Contact Details

If you would like someone from our staff to contact you regarding an inquiry for yourself, a child or a friend – please fill out the following information and we’ll be in touch within 24 hours.

If you are experiencing an immediate medical or mental health emergency, please dial 911.

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Phone ContactPsychiatric Evaluation/Psychiatric Progress ReportsClinical Assessment, Treatment Plan and/or NotesLetters Regarding Treatment Needs/IssuesEmail Containing Clinical Information

This authorization permits the sharing of the above-identified information between the staff of U ARE HEARD
LLC and:

I understand that the information being obtained/released is for the purposes of treatment planning. I understand that I may withdraw this consent at any time prior to the release of the above information and that withdrawal of this consent must be done in writing. I understand that refusal to grant consent will not impede my right to obtain present/future treatment so long as the disclosure is not deemed as necessary for providing appropriate clinical care. This consent will expire on or 6 months from the date of signature.

Address

152 Simsbury Rd
Avon CT 06001

Phone

860-214-7583

Email

info@uareheard.com