Turning Point Counseling
14943 Desman Road, La Mirada, CA 90638
800-998-6329
Please Fax completed form to 714-367-2171

AUTHORIZED TO RELEASE PSYCHIATRIC RECORDS

PATIENT NAME:  _________________________________  BIRTHDATE: ________________________

I HEREBY AUTHORIZE the following releases: Turning Point Counseling, its agents, employees, or servants may disclose my psychiatric and/or psychological records and information obtained in the course of my diagnosis and treatment at this facility to:

NAME: ______________________  AGENCY/FACIUTY/SCHOOL/PHYSICIAN: _____________________

STREET ADDRESS _______________________________State: __________  Zip: _____________  PHONE: ____________________

WHO MAY INTURN, release psychiatric and/or psychological records and information to Turning Point Counseling and its agents.

Personal contact, including phone calls, e-mail, or by other electronic means, or face-to-face meetings may be initiated by either party when deemed necessary, within the time‑frame specified.

PURPOSE (S) OF RELEASES:

Such disclosure shall be limited to the following specific information.

 DISCHARGE SUMMARY

PSYCHIATRIC HISTORY AND MEDICAL STATUS

EDUCATION ASSESSMENT AND REPORTS                                                                              

PROGRESS NOTES AND BRIEF REVIEW

RESULT OF PSYCHOLOGICAL TESTS

LAB REPORTS 

This consent is subject to revocation by the undersigned at any time, except to the extent that action has been taken in reliance thereon and if not earlier revoked it shall terminate on __________________.

Law prohibits release or transfer of the disclosed information to any person or entity not specified herein. An additional consent must be obtained for future transfer or information.

I understand that I have the right to receive a copy of this authorization if I so request. (A copy is valid as the original.)

I am fully aware that certain state and federal statutes and regulations require that I voluntarily sign this document before Turning Point Counseling can release any records, and that I may refuse to sign my signature, but in that event the records cannot and will not be released by Turning Point Counseling. I free both above named parties of any liability if ever I revoke my decision to release the data.

PATIENT SIGNATURE: ______________________________  DATE: ______________________

WITNESS SIGNATURE: _____________________________  DATE: ______________________

PARENT/GUARDIANIRESPONSIBLE PARTY SIGNATURE: _______________________   DATE: _______

THERAPISTIPHYSICIAN SIGNATURE: ______________________________________  DATE: ________