Mental Health Information Release Form

Lets a patient name who their therapist may share clinical information with and confirm it with a signature. Ideal for counseling practices and treatment centers.

Use this template

In the Claude connectors directory

Full name

First Name

Last Name

Date of birth

Email address

Phone number

Address

Street Address

City

State / Province

ZIP / Postal Code

Authorized recipients

Primary care physician Family member Psychiatrist Insurance provider School or employer Attorney

Authorized person's name

First Name

Last Name

Authorized person's phone

Authorized person's email

Authorized person's address

Street Address

City

State / Province

ZIP / Postal Code

Signature

Sign here

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