* Date:

* What is the client's first and last name?

* What is the client's date of birth?

* What is the client's listed email address?

* What is the client's full address or listed address?

* I authorize Josephine Ampaw (Josephine Ampaw-Greene) and Ampaw Psychotherapy and Consulting to (check one or both):

OBTAIN AUTHORIZED INFORMATION FROM

RELEASE AUTHORIZED INFORMATION TO

* The following information:

Medical history and evaluation(s)

Mental health evaluations

Developmental and/or social history

Educational records

Progress notes, and treatment or closing summary

Specific Information Discussed in Session (Or Information to Specifically not disclose)

* What is the name of the person or organization of the person Josephine will be speaking with?

* What is the best way to contact them?

Fax Number

Phone Call

Oral

Email

Mailing Address

* I authorize the disclosure of the protected health information by:

Fax

Phone

Oral/Verbal (In Person or Zoom)

Email Interaction

Written

What is the best contact information based on how you authorize the disclosure of the protected health information?

Fax Number(s)

Phone Number(s)

Oral( Please Indicate if this would be in session)

Email Address(es)

Mailing Address

* Your relationship to client:

Self

Parent/legal guardian

Personal representative

Other

* The above information will be used for the following purposes:

Planning appropriate treatment or program

Continuing appropriate treatment or program

Determining eligibility for benefits or program

Case review

Updating files

Other

* Signature:

By checking this, you are eSigning this form.

* I, the client, authorize Josephine Ampaw (Josephine Ampaw-Greene), LCSW, MFTC, MA to to discuss (verbally or in writing) the specified information below that has been brought up during our psychotherapy or evaluation with any person/s or staff of clinic, office, agency, or institution/s named below and receive any relevant information from them.

By checking this, you are eSigning this form.

* I understand that the information to be disclosed may include any or all information involving psychological or psychiatric conditions, drug or alcohol abuse and/or alcoholism, and/or information involving communicable and/or venereal diseases such as HIV/AIDS. I understand that this authorization will expire in one (1) year from the date of signing, unless otherwise specified here:

* I understand that the disclosure of health information is voluntary. I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment, or eligibility to obtain benefits, unless specified in this form. I certify that this request is made voluntarily and that the information given above is accurate to the best of my knowledge. I understand that I may revoke this authorization at any time in writing by sending a letter to the facility Privacy Officer at the contact information above, or their designee. I understand this release of information is required for the purpose of any necessary and ongoing needs inclusive of evaluations and recommendations for further treatment. I understand that my health care record contains information relating to diagnosis and treatment. I authorize the release of all such information listed above; except any items I have specified above. I further understand that I may request to review my records and refuse authorization to disclose all or some of the above health care information. I am not requesting to review the records in advance. I understand that treatment, payment, enrollment, or eligibility for benefits may not be contingent on this authorization. I understand the information disclosed, as permitted by this authorization, may no longer be protected by Josephine Ampaw and Ampaw Psychotherapy and Consulting after disclosure. I do understand that local, state, and federal laws do exist to protect the confidentiality of this information. I understand this consent is also subject to all conditions outlined in the Practice Policies. I authorize the periodic, ongoing disclosure of the above information. This authorization expires when services are discontinued. If authorization is granted following termination of services, the authorization will expire within 90 days after the date of authorization. I understand that I may revoke this consent at any time by written notice to the provider except where the provider has already acted upon an authorized request for the release of a record. I understand that I am entitled to a copy of this authorization. A photocopy of this authorization shall be considered as effective and valid as the original. I understand my revocation will not be effective to the extent that action has already been taken in reliance on it. I understand and I authorize the disclosure of my mental health information to someone who may or may not be legally required to keep it confidential, and understand that it may be re-disclosed and may no longer be protected by the Standards for Privacy of Individually Identifiable Health Information, set forth at 45 CFR Parts 160 and 164. I I understand that I may inspect or obtain a copy of the information to be disclosed. I understand a reasonable fee will be charged for copies of my mental health record. I understand the facility will provide me a copy of the signed authorization form upon my request. If I have questions about disclosure of my mental health information, I can contact the facility Privacy Officer or their designee. I understand that treatment may not be denied if I refuse to sign this authorization, except: 1) If the authorization is the very reason for seeking the health care (e.g., a pre-employment physical), health care may be denied; or 2) If the authorization is for disclosure to a research study, I may be denied the treatment that is part of the study. In addition, the following consequences might occur if I refuse to sign the authorization: 1) If the authorization is to demonstrate to a health plan that a service should be paid for, the health plan may refuse to pay for it, and 2) If the authorizing is sought by an insurer because I am seeking enrollment or eligibility, the insurer may deny me the coverage I am seeking. I understand that a health plan may not refuse payment or benefits if I refuse to authorize disclosure of certain psychotherapy notes. I understand and affirm, by my signature below, that the benefits and disadvantages of releasing the above information, if known, have been explained to me. A copy or telefax of this authorization will be as valid as the original.

By checking this, you are eSigning this form.

If the Client is unable to sign, please provide Witness signature:

Witness Date: