Informed Consent

I/We:

Client (12 yrs and older)

Client Address

Parent/Guardian (if required)

Parent Address

Parent/Guardian (if required)

Parent Address

Consent to the examination, disclosure, transmittal and/or communication of information compiled with respect to the
person(s) named below:

Client Name

Born on:

Between Lutherwood (Mental Health Services) and the party below:

Name of agency, hospital, or professional, etc.

Agency Address

For the purpose of assessment, treatment planning, case management, OSR review, service coordination, and/or

Other purpose or reason

This authorization is effective on

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This consent may be withdrawn or amended (changed) in writing at any time prior to the expiration date, except on action(s)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.

Signature of Person

Signature Date

Signature of Witness

Signature of Parent/Guardian

Signature Date

Signature of Witness

Signature of Parent/Guardian

Signature Date

Signature of Witness