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Web mental health treatment i, _____[insert name of patient/client], whose date of birth is _____, authorize [insert name of social. Web clinical\release of information (9/30/19) page 1 of 2 009l. This form provides your therapist with written permission to. For the rest of your necessary intake forms, check out. Web to release, discuss, or disclose the following: Web click here to instantly download the free release of information form. Full treatment record including all health/mental health information [2 full. Client name/id/dob (or affix label). Web for disclosure of mental health treatment information i, _____[insert name of patient/client], whose date of birth is. Web authorization for release/exchange of information.