Client Authorization

Release of Information

Use this form to authorize the release of your coaching information to a third party.

Client Information

Full Name *

Date of Birth *

Recipient Information

Name of Person/Organization *

Relationship to You *

Title/Position

Organization

Address

Phone

Purpose & Information

Purpose of Information Release *

Information to be Shared *

Coaching session notes and summariesProgress reports and assessmentsGoals and coaching plansRelevant communications and correspondenceContact information and availabilityOther (please specify below)

Duration of Authorization

Start Date *

End Date (or ongoing) *

Note: You may revoke this authorization at any time by providing written notice.

Client Signature

Signature (Type Your Name) *

By typing your name, you are digitally signing this form.

Date *

By signing this form, you authorize the release of your coaching information to the specified recipient. You understand that Mary's Counselor's Couch is not HIPAA-regulated, and the information released may not have the same legal protections as information protected by HIPAA. You have the right to revoke this authorization at any time by providing written notice.