Feel free to fill this out should you need me to communicate with another party regarding your treatment.

This release of information form authorizes information from my records (or my child's records to be shared between: Courtney Boatman and LMFT

Client Name

First Name

Last Name

Date of Birth

YYYY

Client

Is this appointment for you?

Minor (under 18)

Someone else

Client Name

Only complete if client is different from above.

First Name

Last Name

Email Address

Address

Phone

Best number to reach you.

Presenting Problem

Tell me a little about what brings you to therapy.

Contact

Preferred method of contact

E-mail

Phone Call

Text

Any