Your privacy matters deeply to us. Because your information is confidential, we cannot speak with or share information about you with anyone unless you give us written permission. If you would like your therapist to collaborate, coordinate care, or advocate for you with other providers or supports, you can complete a Release of Information form to let us know exactly who you’d like us to communicate with.

This might include doctors, other mental health professionals, school staff (such as IEP team members or counselors), or others involved in your care. You are always in control of who we speak with and what information is shared.

Release of Information

New Clients

Want to print out the form and physically mail it in?

Click here for the PDF version.

If you would like to fill it out digitally, please use the form below.

Fulcrum All-Terrain Therapeutic Services, LLC.

Online & In-Person Support

madcityfulcrum.com

(608) 618-6552

Release of Information Form

Client Name:

Client Date of Birth:

Month

Day

Year

Address

Phone Number:

I authorize communication between Fulcrum All-Terrain Therapeutic Services, LLC and the listed contact for a period of 1 year from date of signature.

Contact information for recipient of consent to release (Provider, Agency, or Individual).

Name:

Address:

Phone Number:

Please provide a description of the kind of information you are authorizing access for (Example: Progress Notes, Support Services, Medical, Mental Health, Treatment Plans, IEP’s, Academic Records, Historical and/or Social History, etc.).

Information shared is limited to:

Any information related to the above listed client.

Client signature (Legal guardian, if under 18):

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Relationship to Client:

Date signed:

Month

Day

Year

Contact

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