Consent for Disclosure and Exchange of Confidential Client Information


I hereby authorize and request:
Family Counseling Service of Aurora
70 S. River Street,
Aurora, IL 60506
(630) 844- 2662 | Fax (630) 844-3084
Consent
Authorized Individual for Record Release
Address of Authorized Individual for Record Release
Regarding: (Check those that apply)
About (Client's Name)(Required)
For the purpose of:
I understand that this consent will automatically expire 364 days from the date of signature unless it is revoked prior to that date.
I understand that my clinical record may contain psychiatric, mental health, developmental disabilities, alcohol and/or drug abuse information, and/or Acquired Immune Deficiency Syndrome (AIDS) and/or HIV test results and information. Only such information and/or records believed necessary for the purpose expressed above shall be released and disclosed. I may inspect and arrange for copies of the records/information to be disclosed. I understand that:
  • • It is my right to revoke this consent for the release of this information at any time, in writing.
  • • I consent to allow release of only the information specified on this consent form.
  • • That the information received cannot again be given to any other agency or person without my written consent.
  • • That the information released may only be used for the purpose itemized above on this consent form.
  • • That it is my right to inspect and copy the information that is to be disclosed.
Should I refuse to disclose the information itemized above the consequences of such refusal (if any) would be the inability to:
  • • Provide continuity of care.
  • • Provide coordination of care
  • • To gather information relevant to evaluation and treatment.
  • • Payment of services by a third party.
Clear Signature
Clear Signature
Clear Signature

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70 S. River Street Aurora, Illinois