Authorization for Release of Information

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Authorization for Release of Information

We understand that information about you and your health is personal, and we are committed to protecting the privacy of that information. Because of this commitment, we must obtain your written authorization before we may use or disclose your health information for the purposes described below unless there is a serious or imminent threat to the health and safety of you or others.. This form provides that authorization and helps us make sure that you are properly informed of how this information will be used or disclosed.

I request that health information regarding my care and treatment at Compassion Counseling be released to the party named below.

2. Name(s) of person(s) who will be receiving this information:

Health information may be released to another healthcare provider free of charge. However, records not going directly to another healthcare provider are copied at the rate of 85 cents per page plus a $15.00 clerical fee for searching and handling (excluding sales tax and postage).. Health records will be released upon payment of all fees.

We will make records available in a timely fashion not to exceed 15 working days. If we're not able to make records available at the time of request, we will inform you of the status of your medical records and produce your medical record within 21 days from the receipt of the request. If the information requested does not exist or cannot be found you will be notified within 15 working days.

Counseling Records:

By signing this form, I authorize release and disclosure of information regarding my treatment at Compassion Counseling  This authorization is valid until the earlier of the occurrence of the death of the individual; the individual reach- ing the age of majority; or permission is withdrawn; or the following specific date (optional):

I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing.  I understand that the revocation will not apply to information that has already been released in response to this authorization.  I understand that authorizing the disclosure of this health information is voluntary. I may refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that the information disclosed may be re-disclosed if the recipient(s) described in this form is not required by law to protect the privacy of the information, and the information is no longer protected by health information privacy rules.

My questions about this form have been answered and the above required information has been completed.



If you are a licensed counselor, a counselor intern or interested in individual or group supervision and would like to join our team, please contact us.

Meredith Akin-Ivey, is a Licensed Professional Counselor-Supervisor and a Registered Play Therapist- Supervisor.  Please E-mail or call her for more details.

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Compassion Counseling
2214 Michigan Ave
Suite F
Arlington, Texas

Phone: (817) 723-1210

Fax: (866) 776-5116

Our Specialities

At Compassion, our counselors have experience counseling a variety of issues including but not limited to: adoption, anxiety, abuse, body image, depression, couples, faith, families, grief, play therapy, parenting, teens, trauma, christian sex therapy, and self-esteem. Please call our office for more information regarding each counselor's specialty.