AUTHORIZATON FOR RELEASE OF INFORMATION I (We) authorize Gary J. Coenen, M.S. of LifeStyle by Choice, 313 Price Place, Suite 206, Madison, WI. to release specific information to include: _______________________________________________________ ________________________________________________________________________________________
from the clinical record of _______________________________________________________ ____________
(Name of client/recipient of Clinical Hypnosis / Counseling Services) (Date of birth)
for the purpose of __________________________________________________________________________ .
(facilitating counseling/consultation, and/or conducting an evaluation, etc.)
I understand that I have the right to revoke this authorization, in writing, at any time by sending notice to Gary J. Coenen of LifeStyle by Choice. I understand that a revocation is not valid to the extent that Gary J. Coenen of LifeStyle by Choice has acted in reliance on such authorization. This authorization is valid until ________________________________________________________________. .
It has been explained to me that If I refuse to consent to this release of information, the following are the consequences, if any:
A copy of this release shall have the same force and effect as the original. (Client Signature(s)) ______________________ Date ________ ______________________ Date ________ ____________________________________ _________ _______________________________ ________ (Client Signature 12 yrs. or older) (Date) (Parent/Guardian Signature) (Date) NOTICE TO RECEIVING FACILITY/THERAPIST: You may not redisclose any of this information unless the
person who consented to this disclosure specifically consents to such redisclosure. I understand that there
is a potential for redisclosure of this information by the recipient and, if that occurs, the information may not
be protected by Federal law.