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Release of
Information 
A Release of Information form must be completed
before we can request or release your records to/from another person or
facility. One Release of Information form must be completed for each transaction. For
example, if you would like us to request informaiton from your physician, one Release must be
completed. If you would like us to request information from your physician and release your records
from Lifeline - then two Release forms must be completed (one for each "leg" of the
release).
Please complete the top of the Release form (your
name, name of the person or facility) and sign the form. If the Release is for your child or teen, please
have them sign as well if they are 12 years-old or older. If you have any questions, please drop an email
to jdavidson@lifelinecounseling.net.
To download a Release of Information form, click on the
following link:
Release of
Information Form - Click Here
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