Denika Y. Douglas, Ph.D. 
Licensed Psychologist (Lic.# 35076)
Licensed Specialist in School Psychology (Lic.# 34421)

4801 Woodway Dr., Suite 300E														    				 (713) 574-8502
Houston, Texas 77056												    			   drdouglas@douglassolutions.com

_______________________________________________________________________________________________

Request/Authorization to Release Confidential Records and Information 

I hereby authorize: 
Person or facility: _________________________________________________________________________________ _______________________________________________________________________________________________
Address: _______________________________________________________________________________________ 
______________________________________________________________________ Phone: __________________
to release information from records about _________________________________________, born on ____________ , and whose Social Security number is ________________________________________, for the following purpose(s): 

	❑ Further mental health evaluation, treatment, or care 		❑ Rehabilitation program development or services 
	❑ Treatment planning 			❑ Research   		❑ Other: ______________________________________

These records concern the time between ________________ and _____________________. 
In the boxes below, the information to be disclosed is marked by an  X, the items not to be released have a line drawn through them and, page numbers are indicated when appropriate. Written dates indicate when those records were mailed to the requester. 
	❑ Intake and discharge summaries ___________   ❑ Medical history and evaluation(s) _________________
	❑ Mental health evaluations _________   			❑ Developmental and/or social history______________
	❑ Educational records ______________ 			❑ Progress notes, and treatment or closing summary _______
	❑ Other: _____________________________________________________________________________________

Select only one: 
	❑ Please forward the records to the address in the letterhead at the top of this form. 
	❑ Please forward the records to this address: _______________________________________________________
    _____________________________________________________________________________________________ 

HIV-related information and drug and alcohol information contained in these records will be released under this con­sent unless indicated here: ❑ Do not release HIV-related information  ❑ Do not release drug and alcohol information.

I have had explained to me and fully understand this request/authorization to release 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 within 90 days, except to the extent that action based on this consent has already been taken. This consent will expire automatically after 90 days from the date on which it is signed, or upon fulfillment of the purposes stated above. 

Request/Authorization to Release Confidential Records and Information 

I have read and understand the Request/Authorization to Release Confidential Records and Information form.  

____________________________________________  	_______________________________  	________________
Signature of client 											Printed name 								Date 
____________________________________  	___________________________	___________	___________
Signature of parent/guardian/representative 				Printed name 							Relationship 		Date 

I witnessed that the person understood the nature of this request/authorization and freely gave his or her consent, but was physically unable to provide a signature.
____________________________________________  	________________________________		____________ 
Signature of witness 										Printed name 									Date 

FORM 49. Briefer form for requesting/releasing confidential records and information. From The Paper Office. Copyright 2008 by Edward L. Zuckerman. Permission to photocopy this form is granted to purchasers of this book for personal use only (see copyright page for details).