{"content":[{"text":"ASSOCIATED PSYCHOTHERAPISTS","bbox":{"left":0.246503,"top":0.034303,"width":0.506883,"height":0.031477000000000005}},{"text":"CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION","bbox":{"left":0.182386,"top":0.087571,"width":0.6352180000000001,"height":0.023648000000000002}},{"text":"I, __________________________, hereby authorize \n (Client’s Name)","bbox":{"left":0.117686,"top":0.129086,"width":0.48415099999999994,"height":0.041409}},{"text":", to","bbox":{"left":0.836078,"top":0.129086,"width":0.02929599999999999,"height":0.023648000000000002}},{"text":"(Therapist’s Name)","bbox":{"left":0.647222,"top":0.150283,"width":0.15264699999999998,"height":0.020212000000000008}},{"text":"___ Obtain information from","bbox":{"left":0.117686,"top":0.18848,"width":0.23405899999999996,"height":0.023648000000000002}},{"text":"AND/OR","bbox":{"left":0.454232,"top":0.18848,"width":0.08763499999999996,"height":0.023648000000000002}},{"text":"___ Disclose information to","bbox":{"left":0.604474,"top":0.18848,"width":0.22547400000000006,"height":0.023648000000000002}},{"text":"Name and address:","bbox":{"left":0.117686,"top":0.229995,"width":0.174491,"height":0.023648000000000002}},{"text":"_____________________________________________ \n _____________________________________________ \n _____________________________________________","bbox":{"left":0.353023,"top":0.229995,"width":0.52049,"height":0.06516299999999997}},{"text":"The following information: \n ___ Diagnosis \n ___ Progress notes \n ___ Prognosis \n ___ Drug/Alcohol History","bbox":{"left":0.117686,"top":0.313063,"width":0.251528,"height":0.09504500000000005}},{"text":"___ \n ___ \n ___ \n ___","bbox":{"left":0.529526,"top":0.33426,"width":0.029411999999999994,"height":0.07384800000000002}},{"text":"Mental Status Exam \n Treatment Summary \n Recommendations \n Other records as specified: \n _________________________","bbox":{"left":0.58835,"top":0.33426,"width":0.28911699999999996,"height":0.09472399999999997}},{"text":"The purpose for such disclosure is: \n ___ Continuity of Care \n ___ Contact with \n ___ Family Involvement","bbox":{"left":0.117686,"top":0.446851,"width":0.32168099999999994,"height":0.07716699999999999}},{"text":"___ \n ___","bbox":{"left":0.529526,"top":0.468048,"width":0.029411999999999994,"height":0.038090999999999986}},{"text":"Referral \n Other","bbox":{"left":0.58835,"top":0.468048,"width":0.063863,"height":0.038090999999999986}},{"text":"This consent is subject to revocation at any time except to the extent that action \n has been taken in reliance upon it. If not previously revoked, this consent will \n terminate upon this date: _____________________.","bbox":{"left":0.117686,"top":0.542028,"width":0.7308830000000001,"height":0.06516300000000008}},{"text":"________________________________ \n Signature of client","bbox":{"left":0.117686,"top":0.625058,"width":0.370098,"height":0.044405999999999946}},{"text":"____________________ \n Date","bbox":{"left":0.647222,"top":0.625058,"width":0.23127399999999998,"height":0.044405999999999946}},{"text":"________________________________ \n Signature of parent, guardian or authorized \n Representative (when required)","bbox":{"left":0.117686,"top":0.687331,"width":0.396241,"height":0.06520099999999995}},{"text":"____________________ \n Date","bbox":{"left":0.647222,"top":0.687331,"width":0.23127399999999998,"height":0.04440500000000003}},{"text":"________________________________ \n Signature of witness","bbox":{"left":0.117686,"top":0.770399,"width":0.37014,"height":0.04440500000000003}},{"text":"____________________ \n Date","bbox":{"left":0.647222,"top":0.770399,"width":0.23127399999999998,"height":0.04440500000000003}},{"text":"120 North Main Street","bbox":{"left":0.24866,"top":0.934988,"width":0.163147,"height":0.018595000000000028}},{"text":"","bbox":{"left":0.425572,"top":0.935652,"width":0.008296999999999999,"height":0.01707700000000001}},{"text":"Brigham City, UT 84302","bbox":{"left":0.447337,"top":0.934988,"width":0.18542499999999995,"height":0.018595000000000028}},{"text":"","bbox":{"left":0.646438,"top":0.935652,"width":0.008296999999999999,"height":0.01707700000000001}},{"text":"(435) 723-2881","bbox":{"left":0.668203,"top":0.934988,"width":0.11254900000000001,"height":0.018595000000000028}}],"images_bbox":[],"images_bbox_not_text_overlap":[]}