Free mental health release of information form

At Therapy Changes, we put your comfort at the forefront of all that we do. We operate smooth office processes so that you can focus on what matters most: your care.

New Client Forms

For your convenience, all required forms will be accessible through your client portal upon scheduling. Individually signed forms are needed for each participant. If you are a part of a couple or family seeking therapy together, you will each need to complete your own forms.

Consent to Treatment

The success of therapy depends upon a high degree of trust between you and your therapist. The required consent to treatment provides an understanding of therapy to fully inform you about what to expect from therapy and from your therapist. Before a therapist can begin sessions with you or your child, the Consent to Treatment form must be signed. If the client is a minor, ALL legal guardians must sign.

Notice of Privacy Practices

The HIPAA Notice of Privacy Practices is required by the government and provides information regarding use and disclosure of your medical information.

• Notice of Privacy Practices

Release of Information

If you would like your therapist to speak to another therapist, medical doctor, family member or another individual regarding your care, please complete and return the following form:

• Authorization to Release Information

Elliot J Gursky, MD Child, Adolescent and Family Psychiatry Home Services Provided Common Questions Appointment Request Helpful Forms Contact Me Privacy & Policy Hot Topics! Elliot J Gursky, MD 609-924-6294 92 Nassau Street Princeton, NJ 08542 US If you're a new patient, please complete the following forms and bring them to your first session. New Patient Questionnaire Consent for Treatment HIPAA Authorization Form PQ-9 Form ADHD-self form page 1 of 2 ADHS-self form page 2 of 2 ADHD-parent form page 1 of 2 ADHD-parent form page 2 of 2 If you would like me to coordinate care with another provider (for example, primary care physician, etc.), complete this form to authorize release of your psychiatric information: Release of Medical Records Form Note: To download Adobe Acrobat Reader for free, click here. Schedule Appointment Start your new path in life and be the change today! Helpful Forms Click here to view and print forms for your appointment Disclaimer

What form is used to allow the release of their medical records?

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What is a release of information in counseling?