Release of Information

Release of Information

Consent and Authorization to use, disclose, and receive mental health information.

This form provides Breakthrough Counseling, LLC with written permission to communicate with other individual providers regarding the client’s treatment (e.g. previous treating therapist, current health care providers, school, etc.). Breakthrough Counseling, LLC is unable to communicate or coordinate care for the client with individuals for whom there is no ROI on file.

Breakthrough Counseling, LLC recommends completing a copy of this form for all individuals who contribute or have contributed to the treatment of the client’s mental health. These forms may be completed at any time, and can be revoked at any time.

(Examples: Primary Care Physician, School/School Counselor, Psychologist, Psychiatrist, Any and All Previous Mental Health Therapists)

Information may be requested/shared for the following purposes:

  • Coordinate care on an ongoing basis with other providers that are also treating the client.
  • Coordinate care on an ongoing basis with internal treatment providers that are also treating the client.
  • Increase understanding of client history, diagnosis, and treatment.
  • Billing and Insurance.

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