BPBCG Client's Full Name *

First Name

Last Name

Client's Date of Birth *

MM

DD

YYYY

Client's Phone *

(###)

###

####

Client's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

(If a minor) Legal Guardian's Name Completing this Form

First Name

Last Name

(If a minor) Legal Guardian's Date of Birth

MM

DD

YYYY

(If a minor) Legal Guardian's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

(If a minor) Legal Guardian's Phone

(###)

###

####

Information to be released: *

What type of information is being released? (Indicate all that apply)

Treatment Summary

Progress Notes

Diagnosis

Psychological Testing Results

Billing/Insurance Information

Other (enter detail below)

Method of Release (check all that apply): *

Verbal

Written

Electronic

Other (enter detail below)

Type Name as e-Signature *

(Client or Guardian if Minor)

First Name

Last Name

Today's Date of Signing *

MM

DD

YYYY