INFINITE GROWTH CONSENT TO RELEASE OF INFORMATION

Note: This form is valid for one year from the date signed unless consumer and/or consumer representative decides to void this release of information for any given reason prior to the one-year expiration date.

First Name

Last Name

Social Security Number

Date Of Birth

Addressee

I, voluntarily give my consent to authorize representatives of INFINITE GROWTH,LLC and the addressee to exchange information as indicated below. This information is to be kept confidential and may not be released to any other agency or individual(s) without my signed consent. The purpose of this information exchange is to provide continuous care and to assist the addressee and INFINITE GROWTH in my treatment. In no way will information exchanged to be used to discriminate against me or to deny me from receiving services at INFINITE GROWTH.

I agree to the terms & conditions

Addressee to release information to Infinite Growth, llc

Verbal exchange between the above-named entity and INFINITE GROWTH Intake Assessment and Treatment Plan Medication List Quarterly Review Transfer/Discharge Summary Physical Examination Records (within one year of date signed) Physician Recommendation for Community Rehabilitation Services Other: ___Information Needed ______________________________________________

INFINITE GROWTH to release to addressee:

Intake Assessment Entitlement Information Rehabilitation Assessment Treatment Plans (ITP, ITRP, and Review) Psychiatric Assessment, Notes, Medication Log Transfer/Discharge

Client Name

Parent /Guardian Name

Client Signature or Parent/Guardian

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Date

THIS RELEASE EXPIRES ONE YEAR FROM DATE THIS FORM IS SIGNED.