test

[md-text label="Releasing or receiving entity - ie court, MDV..."]

[/md-text] [md-text label="Your name" tabletwidth="4" desktopwidth="6"]

[/md-text] [md-text label="DOB" tabletwidth="4" desktopwidth="6"]

[/md-text] [md-text label="Email" tabletwidth="4" desktopwidth="6"]

[/md-text] [md-text label="Telephone" tabletwidth="4" desktopwidth="6"]

[/md-text] [md-text] Information requested by: Joseph Patterson, PhD. CSAT, Crosswinds Counseling Services, 512 E Southern Ave. Ste C, Tempe. AZ. 85282

[/md-text] [md-text]Nature of information to be disclosed:[/md-text]

History and Physical, Drug Abuse record, Educational Report, Court/Legal records, Alcohol abuse records, Treatment Plan Consultations, Psychological Evaluation and Mental Health Records.
[md-text label="Other" tabletwidth="6" desktopwidth="12"]

[/md-text]

[md-text]
This consent for disclosure of information whose confidentiality is protected by federal laws includes special authorization to release medical information under the drug abuse office and treatment act of 1972 (PL 92-255) and the comprehensive alcohol abuse and alcoholism prevention, treatment and rehabilitation act amendments of 1974 (PL 93-282). I certify that this request has been made freely, voluntarily and without coercion and that the information specified above is true and correct to the best of my knowledge. I authorize and consent to the disclosure by the above named facility and/or persons of information, records, documents, reports, clinical abstracts, histories and charts relating 10 my condition, care and treatment and consent to furnishing photostatic copies of same. I understand that I may revoke this consent at any time except to the extent that action has already been taken to comply with it. Without express revocation, this consent will automatically expire 90 days after the termination of treatment at CCS. If I am no longer receiving services at CCS on the date of the signature, the consent will automatically expire 90 days from the date of the signature unless I express written revocation at an earlier date.

Re-disclosure of any medical records by those receiving the above authorized information may not be accomplished without my further written consent.
[/md-text]

SCREENING

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[md-text label="Current living situation - ie living alone, roommate, with family..." tabletwidth="4" desktopwidth="12"]

[/md-text][/md-card]

Emergency contact

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[md-text label="Contact person" tabletwidth="4" desktopwidth="4"]

[/md-text]

[md-text label="Relationship" tabletwidth="4" desktopwidth="4"]

[/md-text]

[md-text label="Telephone" tabletwidth="4" desktopwidth="4"]
[/md-text][/md-card]

Referring Agency

[md-card]
[md-text label="Name of agency"]
[/md-text]

[md-text label="Contact person" tabletwidth="4" desktopwidth="6"]

[/md-text]

[md-text label="Telephone" tabletwidth="4" desktopwidth="6"]

[/md-text]

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DUI:AlcoholDrug