LWC Release of Information Form

Lake Worth Counseling adheres to the Texas Health and Safety Code regarding access to mental health records.

Client must be age 18 and up, a parent/legal guardian, or the client’s legal health care representative to make a request for the release of private health information. Records will be released within 10 business days after receipt of a completed Release of Information form and resolution of any applicable fees or account balances.

PLEASE NOTE: Supervisor shall contact the requesting party by phone or email to process the details of the request & collect appropriate fee if applicable. A Valid ID is required at the time of records pick up or release.

Online Form

Questions??

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Email

info@lwc.care

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Phone

(817) 238-0106

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Fax

(817) 238-8333

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Open Hours

Mon – Thu: 8AM – 8PM
Fri: 8AM – 5PM
Sat: By Appointment Only

Lake Worth Counseling Release of Information Form

Records Request & Fee*
- Mental Health Records: $50.00
- Written Summary Report/Treatment Plan: Counselor’s Self-Pay Rate ($150.00 and up)
- Professional Phone Call/Consultation: $150.00
- Notary/Certified Mail: $35.00
- General Inquiry – I wish for a supervisor to contact me by phone concerning help with general information about treatment, professional or legal matters: No Charge
Client Name*
First Last
DOB*
Month
Day
Year
Name of person requesting records if different than above
First Last
DOB
Month
Day
Year
Relationship to client*
Self/Parent/Other
Phone*
Address*
Street Address City State ZIP Code
REQUEST FOR RELEASE:
Name/Company to release confidential information*
Phone*
Fax
Email*
Please provide additional details of what may be released or discussed with outside party or anything else you think will be helpful to process your request:*
** Your Message contains website links, please remove them to be able to submit your form. Thank you!
AUTHORIZATION:
I authorize Lake Worth Counseling (LWC) to release my or a minor’s confidential mental health information. I agree to hold all parties harmless of such release and I understand after such information is released, it may be re-released by the recipient, and the information may no longer be protected by federal privacy laws or regulations. This consent is valid until the occurrence of the death of the individual, the individual reaching the age of majority, or consent is revoked by written notice to LWC.
Signature of Client/Parent/Legal Guardian*
Date*
MM slash DD slash YYYY
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