Authorizations to Release Protected Information

If requested, please download the correct form, fill in the blank fields, and return to Dr. DiCarlo by email. For court-involved clients, please do not modify any other fields on the forms, including unchecking boxes, unless requested to do so.

BH

Authorization to Release Behavioral Health/Medical Information


SC

Authorization to Release Academic Information


PD

Authorization to Release Police Department Information


TP

Authorization to Release Third Party Payer Information


CC

Authorization for Collaborative Contact with Multiple Providers (Court-Appointed Cases)

Collateral Forms

Please use this form to allow another individual to participate in your counseling process.

CC

Collateral Therapy Agreement


CR

Evaluation Collateral Information Form