I, ______________________________________ date of birth ___________, do consent and authorize the
following by writing YES or NO by each section and completing all applicable blanks:

_______ any Attorney, Agency, Mental Health Center, Case Manager, Counseling Center, School System, Medical
Facility, Physician, Psychologist, Psychotherapist, Pastoral Counselor or other Counselor to provide the above named
Counselor any information about me concerning any illness, injury, medical history, consultation, prescriptions,
treatment plans, progress reports, testing and appraisals or other information from medical, social service, or
consultation records.

_______ communicate by telephone or in writing with my Physician, Case Manager, Attorney or Attorney’s
representative as needed to assist the other professional in working with me.

Name of professional ___________________________________________ Phone _________________
Address ________________________________ City __________________ State, Zip ____________

_______ release all of my counseling records to: Counselor ______________________________________
Address ________________________________ City __________________ State, Zip ____________
Office Phone  ______________________________________________________________________

_______ release my counseling records with the exception of ____________________________________
to:  Counselor ______________________________________________________________________
Address ________________________________ City __________________ State, Zip ____________
Office Phone  ______________________________________________________________________

A photostatic copy of this authorization shall be considered as effective and valid as the original.  At anytime, I may
make written request to withdraw this release of information.  Such withdrawal must be presented to the therapist
to whom this consent was originally given.

____________________________________      _________________      _____________________
Signature of Client or Guardian                              Date signed                    Social security number

Name of minor client or adult client under guardianship is: _______________________________________
If Guardian, legal authority is as:
Parent ___      Custodial parent ___      Trustee ___      Court-appointed guardian __

If other, specify: ___________________________________________________________________
Dr. Donald L. McClune Jr. / Crystal Buchmann
Copyright 2003 - 2018 Compassionate Christian Counseling