Release to Family or SO

Fill out and submit the below digital form or click here for the printable form.

Release of Information to a Family Member or Significant Other
Location
Client Name
I hereby authorize the office of Churchill Counseling Services to release the following information either over the phone or in person to any of the following persons:
Information
- Prescription Information, Actual Prescription
- Sample Medications (given by Physician)
- Scheduling/Appointments
- Other
Please Specify
This authorization will remain in effect until termination of services from Churchill Counseling Services unless another expiration date or event is indicated here:
Release to
Name
Relationship
Phone
Name
Relationship
Phone
Name
Relationship
Phone
I understand that I must inform Churchill Counseling Services immediately if I wish to revoke permission for any of the above individuals from receiving information from Churchill Counseling.
Client Signature
Date
MM slash DD slash YYYY
Parent/Guardian Signature
Date
MM slash DD slash YYYY

Release of Information to a Family Member or Significant Other