Release of Information Form

The Release of Information Form allows you to authorize the sharing of your therapy records with specific individuals or organizations. This form is used to coordinate your care with other healthcare providers or to fulfill special requests for academic, professional, or personal purposes.

Our priority is to protect your best interests while offering expert guidance, informed by over 25 years in counseling and 15 years in psychotherapy. Our extensive experience in healthcare, education, and corporate settings equips us with a deep understanding of the complexities and vulnerabilities that may affect you. This background helps us identify potential issues and offer effective guidance to safeguard your confidentiality and address your needs with sensitivity.

Canada Online Therapy is a private online mental health clinic dedicated to simplifying and streamlining mental healthcare processes. We admit clients who are committed to achieving their therapy goals. Therefore, we reserve the right to refuse requests from clients seeking paperwork without a genuine therapeutic need or those who are not fully engaged in resolving their obstacles.

We aim to reduce bureaucratic procedures while maintaining the integrity of our therapy services. Our practice is geared towards clients interested in a collaborative and empowering therapeutic relationship. We emphasize reinforcing our values and commitment to active participation, ensuring that clients are genuinely engaged in their therapeutic process.

Lee Park, RCT-C, MA, BHons
Canada Online Therapy
www.canadaonlinetherapy.com

Release of Information Form

1. PARTIES INVOLVED:

Disclosing Party (Who is releasing the information):

First name

Last name

Phone

Position

Company name

Receiving Party (Who is receiving the information):

Name, Organization, Address, Phone Number, Email.

2.Purpose of Disclosure

I authorize the release of information for the following purpose(s):

[Specify the general purpose]

3. Consent Time Period and End Date

Duration: Please specify the period during which you approve the sharing of information (e.g., from [Start Date] to [End Date]).

Expiry: Please indicate the date when the sharing of information should stop.

4. Rights of the Individual:

I understand that: I have the right to revoke this authorization at any time by providing written notice to the disclosing party, except where the information has already been released. My decision to provide or revoke consent

5. Confidentiality Statement:

The information released will be kept confidential and used solely for the purpose specified above. The recipient of this information is required to maintain its confidentiality and is prohibited from using it for any purpose other than that stated.

6. Voluntary Consent:

I understand I am providing this authorization voluntarily and that I have the right to refuse to sign this form. My signature below indicates that I fully understand the terms of this release and consent to the release of the information as described.

7. Signature

Date

Signature

Any other information you would like us to know.

Any additional files, information you would like us to have.