C.M.R. 14, 193, ch. 7, CAREGIVER REQUEST FOR DISCLOSURE OF INFORMATION
(You may use additional paper for explanations)
Name of person making request (your name):___________________________________
Address:___________________________________________________________________
Telephone:_________________________________________________________________
Name of Licensed Mental Health professional from whom you are requesting information:__________________
Agency___________________________________________________________
Address:__________________________________________________________
Phone:___________________________________________________________
I wish information regarding:___________________________________________
___________________________________________________________________
Name:_____________________________________________________________
DOB:________________________________________________________________
Address:______________________________________________________________
Phone:________________________________________________________________
My relationship to the person is:___________________________________
Do you live with the person" YES NO
If you do not live with the person, what direct care do you provide them (describe)"_____________
__________________________________________________________-
Do you receive payment for providing direct care to this person" YES NO
I request that you provide the following information (check information you wish to be disclosed).
[] Diagnosis.
[] Behavioral management strategies I may be able to assist with.
[] Treatment plan and goals that relate to the direct care I provide.
[] Medications prescribed, side effects and likely consequences of not taking it as prescribed. (over)
C.M.R. 14, 193, ch. 7, CAREGIVER REQUEST FOR DISCLOSURE OF INFORMATION