Bend Mental Health Counseling Carol Hopwood LCSW ... 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the client's name in the designated fields: First Name, Middle Name, and Last Name.
3. Fill in the Date of Birth and Date initiated fields with the appropriate dates.
4. Select whether you want to release information from or to Bend Mental Health Counseling by checking the corresponding box.
5. Initial next to each type of information you wish to release, such as Treatment Progress or Diagnosis & Status.
6. If applicable, provide additional details in the 'Other' section for any specific information not listed.
7. Specify an expiration date for this authorization or describe an event that will terminate it.
8. Sign and print your name at the bottom of the form, along with the date and your relationship to the patient if necessary.

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