{"content":[{"text":"AUTHORIZATION FOR RELEASE OF INFORMATION","bbox":{"left":0.235376,"top":0.122477,"width":0.4963139999999999,"height":0.020985000000000004}},{"text":"RE: ___________________________________________","bbox":{"left":0.058864,"top":0.174765,"width":0.4570989999999999,"height":0.020212000000000008}},{"text":"Date of Birth: ________________________","bbox":{"left":0.53085,"top":0.174765,"width":0.34897,"height":0.020212000000000008}},{"text":"This is to authorize:","bbox":{"left":0.058864,"top":0.209487,"width":0.156228,"height":0.020212000000000008}},{"text":"__________________________________________________________________","bbox":{"left":0.234559,"top":0.209487,"width":0.647712,"height":0.020212000000000008}},{"text":"__________________________________________________________________ \n (Address)","bbox":{"left":0.235376,"top":0.244563,"width":0.647059,"height":0.037572999999999995}},{"text":"__________________________________________________________________ \n (Phone) (FAX#) (email, if applicable)","bbox":{"left":0.235376,"top":0.296646,"width":0.647059,"height":0.037573999999999996}},{"text":"to disclose and release any information, including psychiatric and psychological records, of the above captioned \n individual to Windhorse Integrative Mental Health who is/are authorized to discuss all matters pertinent to \n the progress of the client.","bbox":{"left":0.058864,"top":0.349071,"width":0.877784,"height":0.05493399999999998}},{"text":"This information is considered instrumental to the ongoing evaluation and treatment of this client.","bbox":{"left":0.058864,"top":0.418831,"width":0.7672359999999999,"height":0.020212000000000008}},{"text":"Data Requested:","bbox":{"left":0.058864,"top":0.453578,"width":0.12872599999999998,"height":0.020212000000000008}},{"text":"________ Psychiatric information","bbox":{"left":0.117688,"top":0.488301,"width":0.26749,"height":0.020212000000000008}},{"text":"________ Social welfare data","bbox":{"left":0.58848,"top":0.488301,"width":0.23327399999999998,"height":0.020212000000000008}},{"text":"________ Psychological testing","bbox":{"left":0.117688,"top":0.523338,"width":0.24992199999999998,"height":0.020212000000000008}},{"text":"________ Rehabilitation records","bbox":{"left":0.58848,"top":0.523338,"width":0.25686299999999995,"height":0.020212000000000008}},{"text":"________ Educational records","bbox":{"left":0.117688,"top":0.558098,"width":0.23915699999999995,"height":0.020212000000000008}},{"text":"________ Legal information","bbox":{"left":0.58848,"top":0.558098,"width":0.22504000000000002,"height":0.020212000000000008}},{"text":"________ Medical information","bbox":{"left":0.117688,"top":0.592821,"width":0.244628,"height":0.020212000000000008}},{"text":"________ other: ________________","bbox":{"left":0.58848,"top":0.592821,"width":0.290478,"height":0.020212000000000008}},{"text":"Date ________________","bbox":{"left":0.176552,"top":0.645245,"width":0.19849100000000003,"height":0.020212000000000008}},{"text":"Signature __________________________________________ \n (Patient or legal guardian)","bbox":{"left":0.389748,"top":0.645245,"width":0.4921770000000001,"height":0.03757300000000008}},{"text":"__________________________________________ \n (Relationship to client)","bbox":{"left":0.470801,"top":0.697644,"width":0.41176499999999994,"height":0.03757299999999997}},{"text":"__________________________________________ \n (Witness)","bbox":{"left":0.470801,"top":0.749765,"width":0.41176499999999994,"height":0.03757299999999997}},{"text":"www.WindhorseIMH.org","bbox":{"left":0.372712,"top":0.821927,"width":0.19713700000000006,"height":0.01923600000000003}},{"text":"NORTHAMPTON Location \n 211 North St \n Northampton, MA 01060 \n Office: 413-586-0207 \n Fax: 413-585-1521","bbox":{"left":0.058864,"top":0.869622,"width":0.21822099999999997,"height":0.08251299999999995}},{"text":"SAN LUIS OBISPO Location \n 1411 Marsh St., Suite 103 \n San Luis Obispo, CA 93401 \n Office: 805-548-8931 \n Fax: 805-548-8930","bbox":{"left":0.372712,"top":0.869622,"width":0.22717199999999999,"height":0.08251299999999995}},{"text":"PORTLAND Location \n 2120 SW Jefferson St., Ste 300 \n Portland, OR 97201 \n Office: 503-290-3421 \n Fax: 503-290-3618","bbox":{"left":0.686552,"top":0.869622,"width":0.22537399999999996,"height":0.08251299999999995}}],"images_bbox":[{"left":0.301765,"top":0.045455,"width":0.396242,"height":0.061237}],"images_bbox_not_text_overlap":[{"left":0.301765,"top":0.045455,"width":0.396242,"height":0.061237}]}