Release of Information
Acknowledgement of Receipt of Privacy Notice
And Release of Information
  • I have been presented with a copy of Jodi Valentine Counseling’s Notice of Privacy Policies detailing how my information may be used and disclosed as permitted under federal and state law. I also have the opportunity to take home a copy of the policy. I understand that no one, including family members, will be allowed access to any information regarding my treatment or billing information, to include but not limited to, my diagnosis, prognosis, attendance, any and all progress/treatment notes, information regarding compliance with counseling, recommendations for future counseling services and any other information necessary for such coordination of care and any other information requested from person/agency/other to whom information is to be released, unless I include them on the below list. I understand that this office cannot accept my verbal permission to release my information. I also understand that I can change this list at any time. If you were referred to our office by your physician please include his/her name. By law, we cannot discuss anything without you placing their name on the list.

  • By entering your name here, you are digitally signing this online form.
  • By entering your name here, you are digitally signing this online form.