Authorization for Release & Exchange of Information

A Life In Balance, LLC — DBT Skills Training Group

I authorize A Life In Balance, LLC and the individual/provider named below to exchange information in both directions for the purposes of coordinating my care and confirming my eligibility for the DBT Skills Training Group.

Individual Therapist / Provider

Purpose of this authorization

Information that may be exchanged: treatment status and attendance in individual therapy, diagnosis and diagnostic confirmation, relevant treatment and safety information necessary for coordination of care. I understand this authorization does not permit release of psychotherapy notes unless separately and specifically authorized.

Expiration

or one (1) year from the date signed, or 60 days after my participation in the group ends, whichever is earlier.

My Rights

I understand I may revoke this authorization at any time by written notice to A Life In Balance, LLC, except to the extent that information has already been released in reliance on it. Information disclosed under this authorization may be re-disclosed by the recipient and may no longer be protected by federal privacy law. I understand that enrollment in the BPD-Focused cohort is conditioned on confirming the eligibility items above; if I decline this authorization, alternative verification may be discussed.