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LIFE'S LIGHT IN COUNSELING, INC.

Shannon West, L.P.C., AADC, ICAADC, State Approved Supervisor for L.A.C.'s

State Approved Technology-Assisted Supervisor for L.A.C.'s

State Approved Technology-Assisted Counselor

Qualified EMDR Therapist

479-530-8201

Authorization to Release Mental Health Care Information

This request and authorization applies to:
How would you like this information released?
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Thank you! Your request and authorization to release this information has been submitted successfully. I will contact you within 24 hours to discuss this request.

I understand that my express consent is required to release any Mental Health Care information relating to diagnosis, testing, mental health treatment, treatment for HIV, sexually transmitted diseases, psychiatric/mental health disorders, and/or drug and/or alcohol use. I understand that this authorization expires one year after the date it is signed and may be revoked at any time upon written request of the client except to the extent that action has already been taken.I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer be protected by Federal privacy regulations. I understand that my refusal to sign this Authorization will not jeopardize my right to obtain present or future treatment except where disclosure of the information is necessary for the treatment. My treatment and payment for treatment will not be affected if I do not sign this form. I understand that I can request a copy of this form after I sign it.

I understand that I may be asked to pay a fee of $0.50 per page depending on the type and length of the documentation to be released.

By signing below, I acknowledge that I have read and understand this Authorization. 

Signature of Client or Client's Guardian/authorized representative

Date Signed:  

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