General Information and Consent & Notice of Privacy Practices for Clients in the Therapy Practice of
Ronald Mah, M.A., Ph.D. Licensed Marriage & Family Therapist
This form is to authorize, request, give permission for, and consent to psychotherapy services from the practice of
Ronald Mah, M.A., Licensed Marriage & Family Therapist, MFT32136
Authorization for one Professional to RELEASE Confidential Information to Another Professional or Person
Uses for this form include for giving permission for the therapist or another professional to give information about the client to another person such as a doctor, teacher, attorney, family member, or other person.
This form allows for one-way communication of confidential information, but does NOT give permission for the two parties to exchange information- for example, to mutually consult with one another about the client.
Authorization for Therapist and another Professional or Person to EXCHANGE Confidential Information
Uses for this form include for giving permission for the therapist and another professional share their respective information and mutually consult about the client.
This form allows for two-way communication of confidential information. It gives permission for the two designated persons to exchange information- for example, to mutually consult with one another about the client.