Release of Information Client Name* I, _______________ (client), hereby authorize Dr. William R. Boyd. Jr. (therapist) and the following party or parties to discuss my mental health treatment information and records obtained in the course of psychotherapy treatment, including, but not limited to, therapist's diagnosis:Authorized Parties* Please note that treatment is not conditioned. upon your signing this authorization, and you have the right to refuse to sign this form.Please indicate your preference regarding the information to be shared:Limitations* The parties stated above may discuss my medical and / or mental health information without limitations. I would prefer to limit the information shared between the parties stated above. The limitations I would like to make are as follows: Noted LimitationsAdditionally, the above named parties, therapists & person(s) or entity (entities) designated, agree to exchange information only between themselves (or their agents). Any disclosure of information extended beyond these parties is considered a breach of confidentialityYour signature below indicates that you understand that you have a right to receive a copy of this authorization. Your signature also indicates that you are aware that any cancellation or modification of this authorization must be in writing, and you have the right to revoke this authorization at any time unless the therapist stated above has taken action in reliance upon it. Additionally, if you decide to revoke this authorization, such revocation must be in writing and received by the above named therapist at SteppingStone Retreat For Enhanced Living - P.O. Box 733 - 781 Sunset Drive - Dayton, TN 37321 to be effective.Consent* Submission of this form indicates an electronic signature Δ