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Release of Information Form

Legal and ethical guidelines require SCA to obtain your signature on a Release of Information form before disclosing information about you or your therapy to a third party. Specific exceptions to this requirement are spelled out in our Notice of Privacy Practices.

When you fill out the release form, you will need to check one of two boxes to indicate the purpose for the release. Please make sure your therapist tells you which of the two boxes to check.
By crossing out listed items or writing item(s) in, you can specify what kind(s) of information you wish to include or exclude from this release. The release will expire on year from the date of your signature unless you specify otherwise.

Please make sure someone observes your signature who can vouch for your identity, and have that person sign on the line labeled “Witness.”

NOTE: To view these forms, you will need a current PDF viewer installed on your computer. Click here to download a free PDF reader if your computer does not have one.