"Change Happens Because Of A Caring and Listening Ear"

Print Name

Date of Birth

Last 4 of SSN

I authorize Venerable Counseling Services, LLC to obtain and disclose to and/or obtain from the following person/organization:

Description of Information to be Disclosed

Diagnosis
A/D screen results
Anger Management Evaluation
Mental Health Evaluation
Attendance and Progress
Recommendations
Substance Abuse Evaluation
Discharge
Psychosocial History

Other:

Purpose

Compliance

Other:

Revocation

I understand that I have a right to revoke this authorization, in writing, at any time by sending written notification to Venerable Counseling Services, LLC at 235 E. Ponce de Leon Ave., Suite 225, Decatur, GA 30030.. I further understand that a revocation of the authorization is not effective to the extent that action has been taken in reliance on the authorization.

Expiration (put date of expiration)

Unless sooner revoked, this authorization expires on the following date: or as otherwise indicated:

Form of Disclosure

Unless you have specifically requested in writing that the disclosure be made in a certain format, we reserve the right to disclose information as permitted by this authorization in any manner that we deem to be appropriate and consistent with applicable law, including, but not limited to, verbally, in paper format or electronically.

Redisclosure

I understand that there is the potential that the protected health information that is disclosed pursuant to this authorization may be redisclosed by the recipient and the protected health information will no longer be protected by the HIPAA privacy regulations, unless a State law applies that is more strict than HIPAA and provides additional privacy protections. I will be given a copy of this authorization for my records

Electronic Signature

Today's Date

User Agreement

By clicking submit are signing electronically and you are saying you understand the release of information and have signed this on your own accord.