Consent for Release & Exchange of Confidential information

I, ___________ ________________ D.O.B.: / / , SSN: _____________,

hereby give my permission, request, and authorization for
William A. Schroeder IV, MA, LPC & JUST MIND, its affiliates, agents, employees, or servants and

__________________________________________________________________________________________________
Agency/Facility Name Address State Zip

____________________________________________________________________________________________________________
Contact Name & Title Phone & Area Code Fax E-Mail
to release and exchange with each other information pertaining to my medical, legal, psychological, alcohol/drug (including urine analysis),
social, vocational, and/or educational records and professional opinions resulting from my contacts with or concerning treatment/services
and discharge summaries with above. Either party when deemed necessary, within the time-frame specified, may initiate personal contact,
including phone calls, e-mail, or by other electronic means, or face-to-face meetings. This consent and authorization may be revoked at
any time or without revocation, except to the extent that action has been taken in reliance thereon and if not earlier revoked, it will expire
one year from the date signed and rendered valid. I understand that no information gathered will be available to an employer or any
agency other than William Schroeder, MA, LPCI, JUST MIND, and its agents without specific written consent by me.

PURPOSE (S) OF RELEASES: Disclosure shall be limited to the following specific information.
INTAKE & DISCHARGE SUMMARY PSYCHIATRIC HISTORY, MEDICAL STATUS,
DIAGNOSIS & PROGNOSIS

EDUCATION ASSESSMENT & REPORTS PROGRESS NOTES & BRIEF REVIEW

PSYCHOLOGICAL TESTS RESULTS LAB REPORTS & CONSULTATION REPORTS

Law prohibits release or transfer of the disclosed information to any person or entity not specified herein. An additional consent must be
obtained for future transfer or information.

I understand that any cancellation or modifications of this authorization must be in writing, and that I have a right to receive a copy of this
authorization if I so request. A photocopy of this authorization shall be as effective and valid as the original.

I am fully aware that certain state and federal statutes and regulations require that I voluntarily sign this document before William
Schroeder, MA, LPC., Just Mind, and its agents can release any records, and that I may refuse to sign my signature, but in that event the
records cannot and will not be released by William Schroeder, MA, LPCI., JUST MIND, and its agents I furthermore release all parties
stated here within from any legal liability resulting from the release of this information, including if ever I revoke my decision to release the
data, with the understanding that all parties involved will exercise appropriate safeguards while using this information.

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Signature of Client / Guardian Date Signed

_______________________________________________________________________________
Witness / Counselor / Doctor Date Signed

Prohibition on Re-disclosure: “This information has been disclosed to you from records whose confidentiality is protected by Federal law.
Federal regulations (42 CFR part 2 and 45 CFR Subtitle A, Subchapter C, as amended in Parts 160 & 164) prohibit you from making any further disclosure
of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations.
A general authorization for the release of medical or other information is NOT sufficient for this purpose.”
“THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION–PLEASE REVIEW IT CAREFULLY.”

JUST MIND | Tel: 512.524.7172 Fax: 801.780.8217 Email: ws@justmind.org