BetterNOW Mental Health, LLC

    betternowmentalhealth.com
    Marian Aguwa, LCSW-S, BCD
    (248) 914-2675 – marianaguwa@gmail.com
    P.O. Box 131073 , Houston, TX 77219-1073

    Authorization for Release of Information

    Name of Client

    Date of Birth

    Social Security Number

    I understand that Texas law requires each client's consent for the release of confidential information related to mental health or developmental disability. With this understanding, I hereby waive any right to confidentiality arising under Texas law and authorize the release of records of information, but only the extent specified below.

    I authorize BetterNOW Mental Health to release and/or receive the following information concerning myself or my child:

    ▪ Diagnostic Evaluation Results

    ▪ Educational Records

    ▪ Progress Notes

    ▪ Treatment Plan

    ▪ Treatment Summary

    ▪ Discharge Reports

    ▪ Any and All Records

    ▪ Other

    The above information is only to be released to, and/or from, the following party:

    Name and/or Agency

    Address, City, State, Zip Code

    This information is to be used for the purpose of

    This authorization shall remain in effect until at which time it shall expire and no further release of information shall be made under its terms. I understand that I can revoke this authorization at any time by giving written notice to the parties named above. I also understand that I have the right to examine and copy the information disclosed.

    I hereby release the parties named above from any liabilities for release of this information.

    Signature of Client

    (Enter Your Full Name Here)

    Electronically Signed No Signature Needed

    Date

    Signature of Witness

    (Type N/A-If Not Applicable)

    (Enter Your Full Name Here)

    Electronically Signed No Signature Needed

    Date

    Services

    Quick Links

    Contact Us

    Copyright @ 2021 Betternow. All Rights Reserved.