Leslie C Kilpatrick, M Ed , LCSW, LLC POBox 204 Oakton, VA 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your name in the 'Name of client' field. This is essential for identifying the individual authorizing the release.
3. Select the specific information you wish to authorize for release by checking the appropriate boxes under 'Release of Information'. You can choose all treatment records or specific documents like intake assessments or case notes.
4. Indicate whether the information will be released from Leslie Kilpatrick to a second party, received from a second party, or exchanged between both parties by checking the relevant options.
5. Fill in the details of the second party including their name, address, and phone number in the designated fields.
6. Specify the purpose of this authorization by checking all applicable reasons such as treatment planning or coordination.
7. Finally, sign and date where indicated. If applicable, a parent or guardian must also sign if the client is a minor.

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