Client Info Release Form - The Village Network 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the client’s name and date of birth in the designated fields at the top of the form.
3. Fill in the Social Security Number and any other legal names, ensuring accuracy for proper identification.
4. Specify the organization authorized to release information by filling in its name and address.
5. Indicate whether you are releasing information to, obtaining from, or exchanging with The Village Network.
6. Select the specific types of information to be released by checking the appropriate boxes, such as Treatment Summary or Psychiatric Evaluation.
7. Provide a purpose for this information release in the designated section, ensuring clarity on its intended use.
8. Review all entries for accuracy before signing. Ensure that you understand your rights regarding this consent.

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