David A. Yeats M.S.W., L.C.S.W.
Psychotherapy and Consultation Services
350 Broadway, Suite 102
Boulder Colorado 80305
Authorization for Release of Information
At times it may be necessary or useful to either give information to or receive information from individuals or agencies with whom a client is or has been involved, in order to coordinate and support successful therapy. This exchange of information must be authorized by the client in writing. This written authorization serves to document client knowledge and agreement to exchanging information.
I, __________________________________________, (client name), whose date of birth is _____________________,
and whose social security number is _______________________, do hereby authorize David Yeats MSW, LCSW, to
[ ] give information to, and/or
[ ]receive information from:
Name of Individual or Agency ________________________________________________________________________
Relationship to Client ______________________________________________________________________________
Phone Number(s) _________________________________________________________________________________
Any exceptions should be noted here: ________________________________________________________________
By signing below I authorize this exchange of information, good for one year from the date below. I understand that
I can revoke this release at any time. I also acknowledge that a fax or email of this Authorization shall be as valid
as the original.
Client Signature _________________________________________________ Date ____________________________