Leslie C Kilpatrick, M Ed , LCSW, LLC POBox 204 Oakton, VA 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the client's name in the designated field at the top of the authorization form. This is crucial for identifying who the information pertains to.
3. Select the specific types of information you wish to authorize for release by checking the appropriate boxes. Options include treatment records, intake assessments, and more.
4. Indicate whether the information will be released from Leslie Kilpatrick to another party, received from another party, or exchanged between parties by checking the relevant options.
5. Fill in the second party's details including their name, address, and phone number in the provided fields.
6. Specify the purpose for which this information is being released by checking all applicable boxes such as treatment planning or coordination.
7. Ensure that all signatures are completed at the bottom of the form. This includes client signature, date, and if applicable, parent/guardian signature and witness.

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