Authorization to Obtain and Release Information

Patient (required)

Date of Birth (required)

Information being Obtained/Released
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:

Phone

Contact Person

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.

Please sign here