ROI Form - SpringSource Psychological Center

I hereby authorize SpringSource Psychological Center, PLLC to release/obtain information about:
Name*
First Last
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
To/From the Following:
Name*
First Last
Phone
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Relationship:*
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 Summaries
- Medical History and Evaluation
- Confirmation of Admission
- Treatment Plan
- Diagnosis
- Summary of Course of Treatment
- Treatment for Substance Use if Applicable
- Other
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.
Client Name:*
First Last
This entry acts as a client signature.
Date:*
MM slash DD slash YYYY
This form has been modified from The Paper Office. Copyright 2008 by Edward L. Zuckerman.