Authorization for Release of Medical Records

I (client), DOB:
Here hereby give permission to
(therapist) of
Inner Light Counseling and Holistic Center,
285 East Main St, Somerville, NJ, 08876
to release information to and receive information
from (name or organization)

For the purpose of

Description of information to be disclosed:

  • Presence or Participation in treatment
  • Demographic Information
  • Intake and Assessment
  • Psychosocial Evaluation
  • Treatment Plan or Summary
  • Progress Notes
  • Discharge Summary
  • Disability/FMLA Form
  • Itemized Bill
  • Other
This authorization shall remain in effect until 6 months from the date of cessation of treatment, unless revoked in writing at an earlier date.
Please see our Notice of Privacy Practices for more information on how your Protected Health Information is used and kept confidential by Inner Light Counseling.

Client Signature Date
Parent/Guardian Signature