Authorization for Release of Psychotherapy Notes

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I hereby authorize ___________________________ to release my psychotherapy notes to the person named below. I realize this information may be seen by the person noted below, as well as additional staff at his/her agency and that this is beyond your control.

I understand I have a number of rights under Illinois Law explained in The Notice of Illinois Psychologist’s Policies and Practices. Among these are that I have the right to a copy of the psychotherapy note summary report, and that should I disagree with the conclusions, I have the right to submit a two-page, typed, addendum to my file for consideration. If accepted, this would be stored with the summary report, detailing the reasons for my disagreement(s), and would then be sent with the summary report in the event it is released in the future. If the addendum is not accepted, I have the right to appeal this decision.

Further, I understand that the original psychotherapy notes and the summary report will be retained in your file, and securely stored for several years. I realize that this information may be used to train future psychologists, or to conduct research on the effectiveness of psychotherapy. In either case, any identifying information about me will be removed so my privacy and confidentiality are protected.

By signing below, I authorize you to release a summary report of psychotherapy notes

regarding ______________________________ to ______________________________
(print client name and agency of person)

This information is being released for the following reasons:
______________________________________________________________
("at the request of the individual" is all that is required if you do not desire to state a specific purpose)

I understand I have the right to revoke this consent in writing at any time. The consent is
valid for one year, ending on _________/_________/_________. This information may not be re-disclosed without my consent under Illinois Law.

_________________________________________ _________/_________/_________
(sign client name and today's date)

This Consent and Authorization is governed by the Illinois Mental Health and Developmental Disabilities Confidentiality Act (740 ILCS 110) as well as other applicable state and federal laws.