I hereby authorize SpringSource Psychological Center, PLLC to release to and obtain information from: (this should be someone like a medical doctor/psychiatrist/dietitian or emergency contact, etc.)
For the purposes of further mental health evaluation and treatment, and/or Coordination of Care between providers, the following information will be communicated:
Intake and Discharge SummariesMedical History and EvaluationConfirmation of AdmissionTreatment PlanDiagnosisSummary of Course of TreatmentTreatment for Substance Use if ApplicableEmergency ContactOther
I have had explained to me and fully understand this request/authorization to release/obtain records and information, including the nature of the records, their contents, and the likely consequences and implications of their release. This request is entirely voluntary on my part. I understand that I may take back this consent at any time, except to the extent that action based on this consent has already been taken.
This entry acts as a client signature.
This form has been modified from The Paper Office. Copyright 2008 by Edward L. Zuckerman.
How did you hear about us?
We look forward to speaking with you. We have an office at 53 W. Jackson Boulevard, Suite 520 Chicago IL 60604 where you can schedule appointments as well as virtual appointments.
© 2023 SpringSource Psychological Center
Serving Cook County, IL and the following cities: Chicago, Elgin, Cicero, Schaumburg, Evanston, Arlington Heights, Palatine, Skokie, Des Plaines, Orland Park, Glenview