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To: CAPS (The Counseling and Psychiatric Service) Georgetown
I hereby request and authorize the ( __disclosure __exchange ) of information by CAPS
With these parties:
The type of mental health information:
__Attendance (appointments scheduled/met; dates of service)
__Safety concerns (level of danger to self or others) *
__Treatment information (e.g. summary, treatment plan, etc.)
__Alcohol and other drug use
__Mental health records
__Academic related issues
* (Please note that for instances of imminent danger to self or others, confidentiality may be waived.)
This information may be used for the purpose(s) of:
__continuity of care __ coordination of care __addressing academic concerns __family support __medical leave of absence or clearance __other: ___________________
I understand that:
1. My authorization of disclosure of this information can be revoked by providing a written revocation. (Exceptions: where authorization is executed in connection with a client?s obtaining: (1) a life or noncancellable or guaranteed renewable health insurance policy, in which case the authorization shall be specific as to its expiration date which shall not exceed 2 years from the date of the policy; or (2) any other form of health insurance in which case the authorization will be specific as to its expiration date which shall not exceed 1 year from the date of the policy.) However, mental health information disclosed before the receipt of my written revocation may be used for the purposes stated above.
2. This authorization applies only to the disclosure of mental health information which exists as of this date.
3. Information disclosed in accordance with my authorization cannot be further disclosed by the recipient without my consent, unless otherwise authorized by law.
4. Within the provisions of the Mental Health Information Act, I have a right to review the mental health information contained in my record.
This authorization expires in 60 days from today?s date, unless an earlier date is specified: ___________
Signature of Client/Date ____________________________
Printed Name __________________________________
Signature of Witness/Date __________________________