Release Of Information Consent — Kacie LaChapelle, Ph.D.

By electronically signing below I acknowledge that information about me may be released, discussed, and/or disclosed. I understand that my records are protected under Federal Regulations governing Confidentiality of alcohol and drug abuse patient records, 42 CFR Part 2, and cannot be disclosed without my consent unless otherwise provided for the regulations. I also understand that I may revoke this authorization at any time and must do so in writing and present this written revocation to my therapist. I understand that once information is disclosed as per my authorization, the recipient, in accordance with applicable laws and regulations, may re-disclose the information and it might not be protected by federal or state privacy regulations.

Patient Name

First Name

Last Name

Patient DOB

YYYY

I authorize Kacie LaChapelle to disclose and/or obtain treatment information from the following:

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

If you are limiting the information that is released, please list ONLY the information you agree to be released:

Please check the box below to confirm you have read, understand and agree to the terms of this document.

I hereby state that I have read, understood and agree to the terms of this document.