Kathy T. Heustess, MSW, LCSW Office: (865) 692-2390 Fax: (865) 692-2393
This form fully protects your civil liberties when the following conditions are met: 1. All blanks have been filled out prior to your signing it; 2. Signing this is not a condition of treatment; 3. That you sign it only after a specific request has been made; 4. That you fully understand that the release is limited to include only the agency (or agencies) or individual(s) named below. I AUTHORIZE __________________________________________________________ Address: ________________________________________________________________ Phone Number: __________________________Fax: _____________________________ TO EXCHANGE PROFESSIONAL INFORMATION WITH: ______________________________
________________________________________________________________________ ________________________________________________________________________ IN REGARD TO (WHOM) __________________________________________________ FOR THE PURPOSE OF ___________________________________________________ ________________________________________________________________________ Any information you authorize other professional to release to Kathy T. Heustess, MSW, LCSW will be held strictly confidential and will not be released without your permission, within the legal limits of Tennessee State Law and the ethical code of the National Association of Social Workers and the American Association of Pastoral Counselors. Signature: ____________________________________
Date: ___________________
(Client)
Signature: ____________________________________
Date: ___________________
(Parent/guardian, if client is a minor)
Witness: _____________________________________ *Please Fax to:
Date: ___________________
Kathy T. Heustess, MSW, LCSW Director Holston Center for Wellbeing, 2507 Mineral Springs Avenue, Suite B, Knoxville TN 37917-1549
Fax: 865-692-2393 Phone: 865-692-2390 Revised: 5/5/2020