Northland Counseling Center

Committed to Recovery

Release of Information – Agencies & Providers

This release of information is for other AGENCIES or PROVIDERS that you would like involved in your mental health care.

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, Inc 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 to have information requested or provided to other agencies or providers.

If you are receiving medication management services, you will be asked to fill out Release of Information forms for your pharmacy, medical clinic and, if applicable, previous medication provider to name a few.

This form is ONLY valid with a signature.

Release of Information for Other Agencies

"*" indicates required fields

What location is the client receiving services at:
Client's Full Name*
(If you are a Parent/Guardian and are filling this out for your child please put the CHILD’S NAME)
MM slash DD slash YYYY
(If you are a Parent/Guardian and are filling this out for your child please put the CHILD’S DATE OF BIRTH)
I authorize Northland Counseling to give / receive information the below listed agency/person.*
Please indicate WHO you would Northland Counseling Center, Inc to give or receive information to. Please list: AGENCY NAME. If this is for an individual please list their first and last name.
Type of Information to be released/ received/ exchanged:*
Please select a minimum of one document. Information may be released via mail, fax, phone and/or verbal. Progress Notes and Assessment need prior approval from provider and are subject to providers discretion to release.
Understanding:
Purpose of information released/ received/ exchanged:*
Please select a minimum of one option that best fits:
Consent*
MM slash DD slash YYYY
If signing as the authorized representative of the client, I am: