Notice to Recipients of Information:

This information has been disclosed to you from records whose confidentiality is protected by Federal Law. Federal Regulations (42 CFR Par2) prohibit you from making further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is not sufficient for this purpose.

Person, agency or entity to whom information is to be released:

Name: _____________________________________________________________________________________

Address: ___________________________________________________________________________________

__________________________________________________________________________________________

Telephone: _________________________________          Fax: _______________________________________

Email: _____________________________________________________________________________________

This document authorizes Lois Thomson-Bowersock, LCDC, ADC II, CET to disclose information concerning:

Name(s): __________________________________________________________________________________

Address: __________________________________________________________________________________

__________________________________________________________________________________________

Date of Birth: _______________________________________________________________________________

Social Security #: ____________________________________________________________________________

I, the undersigned, hereby consent to, direct and authorize Lois Thomson-Bowersock, LCDC, ADC II, CET to release or disclose confidential records or protected healthcare information pertaining to my treatment and counseling processes with

__________________________________________________________________________________________

________   Initial Assessment/History
________   Treatment Plan
________   Progress Notes
________   Billing Records
________   Transfer/Termination Summary
________   Tests Taken and Testing Scores
________   Other
________   Any and all records and/or protected health information

The purpose of this disclosure is to:

________   Facilitate treatment
________   Comply with legal requirements
________   Facilitate financial considerations for third-party payors
________   Other (specify)
_____________________________________________________
_____________________________________________________

I acknowledge that I have the right to revoke this authorization in writing at any time to the extent that Lois Thomson-Bowersock, LCDC, ADC II, CET has not taken action in reliance on this authorization. I further acknowledge that even if I revoke this authorization, the use and disclosure of my protected heath information could possibly still be compelled by Court Order under state law as indicated in the copy of the Privacy Notice of Lois Thomson-Bowersock, LCDC, ADC II, CET that I have received and reviewed.

I acknowledge that I have been advised by Lois-Thomson-Bowersock, LCDC, ADC II, CET of the potential of the redisclosure of my protected health information by the authorized recipients and that it will no longer be protected by the Federal Privacy Rule. I acknowledge and understand I am waiving my right to confidentiality with respect to the records and protected health information released pursuant to this consent.

I further acknowledge that the treatment provided to me by Lois Thomson-Bowersock, LCDC, ADC II, CET was not conditional on my signing this authorization.

This consent is subject to revocation at any time, except to the extent that action has been taken in reliance thereon. This consent, unless sooner revoked, is valid until:

____________________________________________________________________
(Condition date or event upon which consent will expires without express revocation.)

SIGNED this _________ day of ______________________. 20 _____.

_________________________________________________________
Client

Address: ___________________________________________________________________________________

__________________________________________________________________________________________

Telephone: __________________________________        Fax: _______________________________________

Email: _____________________________________________________________________________________

Social Security Number: ______________________________________

Date of Birth: ______________________________________________

I acknowledge that I have received a copy of this signed authorization from
Lois Thomson-Bowersock, LCDC, ADC II, CET this _________ day of ______________________, 20_____.

_________________________________________________________
Client

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