Authorization Of Disclosure Form

Lisa M Stephen, Ph.D., ACC

Peak Performance Coach

Client Last Name*

Client First Name*

DOB*

Date*

I, the client (or his or her parent or guardian), authorize Lisa M. Stephen, Ph.D., ACC to release oral information and written records to:

Disclosure from:	Release to:
Lisa M. Stephen, Ph.D., ACC PO Box 1034, Jericho, VT 05465 (802) 355-9299	Name*
	Address*
	City, State, Zip Code*
	Phone Number*

The following information/reports may be release:*

Billing Information
Summary of Services Provided

Other

My signature below indicates the following: I fully understand this request and authorization to release information and records. I made this request voluntarily. I understand that I may revoke this consent at any time and no further disclosure will occur after the date of revocation. I understand that if not revoked, this consent will expire when the client’s case is closed. I received an oral explanation of this form

	Signature	Printed Name	Date
Client	*	Printed Name*	ClientSignatureDate* Date Format: MM slash DD slash YYYY
Parent/Guardian	*	Printed Name*	ClientSignatureDate* Date Format: MM slash DD slash YYYY

Notice of Revocation: I, the client (or his or her parent or guardian) revoke the above authorization of disclosure as of this date:

	Signature	Printed Name	Date
Client		Printed Name	ClientSignatureDate Date Format: MM slash DD slash YYYY
Parent/Guardian		Printed Name	ClientSignatureDate Date Format: MM slash DD slash YYYY

PO Box 1034, Jericho, VT 05465 • drstephen@ignitepeakperformance.com • 802-355-9299 • www.ignitepeakperformance.com

BUILDING THE MINDS OF CHAMPIONS

Name
This field is for validation purposes and should be left unchanged.