Skip to content
Home
Overview
Mental Health Disorders
Depression Anxiety
Generalized Anxiety Disorder (GAD)
Panic Attacks
Obsessive-Compulsive Disorder (OCD)
Emetophobia
ADHD
Aspergers Syndrome
Learning Disabilities
Forms of Therapy
Cognitive Behavioral Therapy (CBT)
Dialectical Behavioral Therapy (DBT)
Eye Movement Desensitization and Reprocessing (EMDR)
Biofeedback
Internal Family Systems (IFS)
Types of Therapy
Individual therapy for adults and children
Social Sense Program
Couples Therapy
Family Therapy
Workshops & Trainings
Telehealth Services
Articles
Menu
Home
Overview
Mental Health Disorders
Depression Anxiety
Generalized Anxiety Disorder (GAD)
Panic Attacks
Obsessive-Compulsive Disorder (OCD)
Emetophobia
ADHD
Aspergers Syndrome
Learning Disabilities
Forms of Therapy
Cognitive Behavioral Therapy (CBT)
Dialectical Behavioral Therapy (DBT)
Eye Movement Desensitization and Reprocessing (EMDR)
Biofeedback
Internal Family Systems (IFS)
Types of Therapy
Individual therapy for adults and children
Social Sense Program
Couples Therapy
Family Therapy
Workshops & Trainings
Telehealth Services
Articles
Forms
Release Of Information
Janneta Bohlander & Associates, LLC
Janneta Bohlander, LMFT
246 Post Road East 2nd floor Westport, CT 06880
203-521-0805
Janneta Bohlander, LMFT
CT license number 000955
Tax ID 20-3204106
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
Authorization for Release of Information
Client’s Name:
*
DOB:
Information to be released:
Summary of treatment to date
Report
Other:
Purpose of Disclosure
Coordination of Care
Other:
Persons authorized to make Disclosure:
Person authorized to receive Disclosure:
Method of Disclosure
Written :
Verbal:
Electronic:
Today’s date:
Authorization to expire on:
I understand that my health information is protected by law. I authorize the release of my confidential health information as indicated above. I understand that my consent is voluntary and I can revoke this permission at any time, except to the extent that it has already been shared based on this authorization. Should I choose to revoke this authorization I will state this in writing.
Date:
Submit
