This form outlines the consent and agreement for releasing copies of the patient's medical records. For Belita Proctor.

"*" indicates required fields

Ephesians Professional Counseling

Belita Proctor, MS, CRC, LCPC

State Licensed Clinical Professional Counselor, Certified Rehabilitation Counselor



Client Information

Please fill in this section with the Client's information.


Release of Information

I hereby authorize the release of the following clinical information about me (or about my child or ward) TO and/or FROM Belita Proctor, MS, CRC, LCPC by verbal or written means. E-mailing clinical information is prohibited.

Select all that apply
List any other forms of information which are authorized for release with this form.

Organization or person with whom Belita Proctor, LCPC will communicate:

  • I understand that Belita Proctor, MS, CRC, LCPC cannot be held responsible for re-disclosure of protected health information once it has been released to another party.
  • I understand that I may revoke or terminate this authorization by submitting a written request to Belita Proctor, MS, CRC, LCPC otherwise this authorization will be effective for 2 years from the date of signature.
Person signing*
I acknowledge that I am 18 years old or have legal authority to sign for the Client*
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.