MINOR  – PERMISSION TO RELEASE INFORMATION

  • I hereby give my permission for the release and/or exchange of pertinent medical, psychological, personal, drug and alcohol, and/or educational records between INSIGHTS GROUP and the following person(s) or agencies for the purpose of treatment coordination:
  • Please note: If you are receiving therapy to treat an eating disorder, it is required that you simultaneously work with a dietitian. If you do not yet have one, a referral list can be provided to you with the expectation of having a dietitian in place within the first two months of therapy.
  • MM slash DD slash YYYY

Please wait for the confirmation before closing out of the form.

NOTICE TO THE PERSON[S]/AGENCIES/OTHER[S] FROM WHOM RECORDS ARE BEING REQUESTED

All records received by Insights Group will be available for inspection by the parent, legal guardian, surrogate parent, or adult student. Records will be re-released upon receipt of written permission from the patient.

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