About this template
A Mental Health Care Release of Information Form is essential for mental health practices, counseling centers, and healthcare institutions seeking formal, legal client authorization to share confidential treatment records with external parties. This form ensures full compliance with patient privacy expectations while establishing clear boundaries on what specific health information can be disclosed, who receives it, and for what precise clinical or administrative purpose.
Using Doc2Form, mental health providers can instantly convert traditional intake documents into ready-to-use Google Forms, eliminating paper clutter and streamlining the patient consent workflow. By capturing structured authorization details—such as disclosure timelines, authorized entities, and specific clinical notes to include—clinicians protect patient confidentiality and maintain meticulous audit trails for treatment planning. It provides a secure, transparent, and frictionless experience for clients while keeping administrative overhead to an absolute minimum.
Key features
- Collect clear client authorization for sharing mental health records.
- Specify exact disclosure purposes and restricted information types.
- Define clear start and end dates for authorization validity.
- Built natively on Google Forms for seamless team collaboration and storage.
Use cases
Coordinating patient care between a primary therapist and a psychiatr…
Coordinating patient care between a primary therapist and a psychiatrist.
Releasing treatment summaries to insurance providers or legal represe…
Releasing treatment summaries to insurance providers or legal representatives.
Transferring client files securely to a new healthcare facility upon …
Transferring client files securely to a new healthcare facility upon patient request.
What this form collects
- Authorization Type (Multiple choice)Select whether you are initiating a new release of information or revoking an existing authorization.
- Client Full Name (Short answer)Enter your full legal name.
- Date of Birth (Date)Enter your date of birth.
- Disclosing Party / Facility Name (Short answer)Name of the mental health provider or institution releasing the records.
- Receiving Party Name (Short answer)Name of the person, organization, or facility receiving the records.
- Receiving Party Contact Information (Paragraph)Provide the address, phone number, and email or fax of the receiving party.
- Purpose of Disclosure (Dropdown)Select the primary reason for releasing this information.
- Information to Be Disclosed (Checkboxes)Select all types of records you authorize for release.
- Authorization Expiration Date (Date)Specify the date or event upon which this authorization expires.
- Client Acknowledgment & Signature (Short answer)By typing your full name below, you confirm that you understand and voluntarily authorize the release of your confidential mental health information as specified above.
- Date Signed (Date)Enter today's date.
FAQ
Can I customize the fields to match our clinic's specific authorization requirements?
Yes! Because the template opens directly in Google Forms, you can easily add, remove, or edit any questions to align with your organization's legal and clinical standards.
How do clients sign the release form using Google Forms?
You can include a required acknowledgment statement and a text field for the client's full legal name and date, or use standard digital signature add-ons connected to Google Workspace.
Is the submitted client data secure?
All form responses are saved securely in your organization's Google Drive account, protected by Google's robust cloud security and access controls.
Can I restrict who has access to the submitted release forms?
Yes, you can manage view and edit permissions directly within Google Drive to ensure that only authorized clinical and administrative staff can access sensitive patient responses.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.