Consent to the examination, disclosure, transmittal and/or communication of information compiled with respect to the
person(s) named below:
Between Lutherwood (Mental Health Services) and the party below:
For the purpose of assessment, treatment planning, case management, OSR review, service coordination, and/or
and for twelve months following.
This consent may be withdrawn or amended (changed) in writing at any time prior to the expiration date, except on action(s)
already taken on the authority of the consent.