Certificates in: Play Therapy, Sexual Abuse and Trauma Recovery,

Marriage and Family Therapy, and

Canine Assisted Therapy
Licensed Mental Health Counselor MH 9099
924 N. Magnolia Ave, Suite 210 p 407.312.8295
Orlando, FL 32803 f 407. 704.7999
ehollingsworthlmhc@gmail.com

AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION

Date: ________________________ Continuing Care: YES NO

I _____________________________________ Authorize Elizabeth Hollingsworth, M.A.,

LMHC, Hope Can Heal Counseling Center, LLC to Obtain Release Medical information
in my record, including information of Psychological/Psychiatric, Drug/Alcohol Abuse,
HIV/AIDS related Nature of:

Client Name: ____________________________________________________________

Address: ________________________________________________________________
Date of Birth: ____________________________________________________________

Medical Information to be: Obtained From, Released To,

Name: _________________________________________________________________
Address: _______________________________________________________________
Phone: ____________________________ Fax: _________________________________
For the purpose of: _______________________________________________________

Information to be released: Labs Closing summary Assessments Medication

Other (Specify) ________________________________________________________

Form: Written Verbal Telephone Other

I understand that this consent is revocable upon written notice to the facility, except to the extent
that action by the facility has been taken in reliance on this authorization, and that this consent
will remain applicable for the reasonable time (_________________) in order to effect the
purpose for which it is given. Expiration Date
Psychiatric, Alcohol/Drug Abuse, HIV/AIDS information disclosed from records whose confidentiality is protected
by state and federal law (FSS, 394, 397, & 381; 42CFR, Part II; and 45CFR, Parts 160 and 164,) may be subject to
redisclosure by the recipient and no longer protected. Further disclosure will not be produced without specific
written consent of the authorized individual, or as otherwise permitted by such regulations.
_______________________________________ ________________________
Client Signature/Legal Representative Signature- Specify Relationship Date of Signature

2017