Forms and Resources

Welcome to our Forms and Resources page! Here, you'll find essential documents and helpful materials to assist you.

Release of Information

Full Name:*

Date of Birth*

Month

Day

Year

I authorize The Place Psychological Services, PLLC to release and/or receive the following information to/from:

Name/Organization*

Email or Fax*

Phone*

Purpose of disclosure:

Select all that apply*

Coordination of Care

Treatment Purposes

Personal

Legal

Billing

Other

Information to be released

Select all that apply*

Diagnosis

Treatment Dates

Progress

Treatment Summary

Other

This authorization will expire one (1) year from the date of signature unless otherwise specified.

I understand that I may revoke this authorization at any time in writing, but that it will not apply to any actions taken prior to the revocation.

Signature*

Sign in the box or use the keyboard to type.

Signature field is empty.

If signed by someone other than the client, indicate relationship:

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