Date* MM slash DD slash YYYY Client's Name* First Last Date of Birth* MM slash DD slash YYYY Age*Social Security Number*Parent/Guardian's Name(if applicable)Relationship To Client*Is there a custody agreement?* Shared Sole Joint Who has legal decision-making power for medical/psychological treatment?*Signature of legal decision-maker for treatment:*Patient's Phone*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Authorization*I authorize a two-way release of records/information between the following individuals/facilities and Building Blocks Family Counseling: Yes Facility/Person*Phone*FaxType* Entire record Attendance Insurance Info Evaluation Results Valid For* 3 months 6 months 1 year Authorization*I understand and verify that due to COVID-19 this is a virtual signature and has the same implications as a regular signature. Yes Signature*Date* MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.
