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Date of Birth * Name *
* Phone * Email *
Coach/Therapist Information Name
Name of Practice Address
Information will be released to:
9813 Crestline Drive
Knoxville, TN 37922
Relationship to Client is: Coach, Group Facilitator, and/or Retreat Facilitator Please select the support professional your information can be released to: * Group Facilitator with Hope Redefined Retreat Facilitator with Hope Redefined Coach with Hope Redefined
Please check all areas that your info can be released in case there are different support persons responsible for one of your services.
What can be released between these two parties? * Whether you are receiving services with a coach Prognosis (diagnosis, opinion of how treatment will benefit you, general issues about the situation) Nature of case (Services offered, purpose and philosophy of coaching Brief statement regarding progress (your response, your understanding of the situation and the SA/partner concept, progress or lack of progress on goals, cooperation with plan and goals) Support and coordination for Therapeutic Disclosure Why is information being released? * Referral to other services Coordination of care Consultation with Doctor Consultation with other mental health provider Transfer of Care Other (please specify below) Therapeutic Disclosure This authorization lasts for one year after the date of submission unless otherwise noted by the client in this form.
This authorization may be canceled in writing at any time. An email of this authorization will be treated in the same way as an original.
By checking the box below and inputting your name this holds the same authorization as your signature. Your agreement indicates that you have read and understand this form, and authorize release of your information as described above. * I agree to the contents of this form and agree to the release of information as stated in this agreement between Hope Redefined and my professional practitioner Date *
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Client Name (Signature) * Additional Notes: