This release of information is for FAMILY or FRIENDS that you would like involved in your mental health care. If you would like your family or friends to have access to more information please contact reception for an appropriate release of information.
This release is ONLY good for ONE YEAR, unless you contact Northland Counseling Center, Inc and state you would like to revoke an ROI. Without your permission, Northland Counseling Center, cannot release information to other parties. We can release information without a release if there are Mandated, Vulnerable Adult, or Duty to Warn reports.
When filling out this form, please fill it out to the best of your ability and fill in all the required fields. This is NOT mandatory and only needed if you would like Family or Friends to be involved in your mental health care.
This form is ONLY valid with a signature.