TEMPLATE FOR THERAPISTS
Release of Information
Most Release of Information forms are a wall of legal language that clients skim, sign, and forget. The problem is that a poorly completed or poorly understood ROI can create real clinical and ethical problems—disclosing more than intended, covering the wrong providers, or leaving out key protections around sensitive information like substance use records.
This is a full, editable Release of Information form template designed for private practice therapists. Every section is written in plain language. Every placeholder is marked in red so you know exactly what to fill in. Customization notes throughout flag decisions specific to your state, your practice structure, and the populations you serve.
It's built for the cases that actually get complicated. It includes sections that most generic ROI forms skip entirely: a records date range to limit disclosure, a minor and guardian authorization block, a clinician acknowledgment line, specific revocation instructions, and a communication preference section so clients can specify how their information gets shared—on every release, not just once.This is for you if you're still using a generic ROI you downloaded years ago and aren't sure it covers everything it should—and especially if any of these sound familiar:
You coordinate care with outside providers—psychiatrists, PCPs, schools, case managers—and need a form that can handle multiple recipients cleanly
You work with minors and need guardian authorization language that's actually built into the form
You've had an ROI create a problem after the fact and don't want it to happen again
You're building a group practice and need a form that works across multiple clinicians
You believe your clients deserve to understand what they're signing—not just sign it
1. Download and open—The template is a .docx file. Open it in Microsoft Word or Google Docs.
2. Replace the red brackets—Every red-bracketed placeholder is a field to fill in: clinician names, practice contact details, your preferred revocation method.
3. Review the teal notes—Throughout the document, teal customization notes flag decisions specific to your state, practice structure, and client population. Read each one, make your choice, and delete the note before finalizing.
4. Remove what doesn't apply—For example, the minor/guardian block if you only work with adults.
5. Save as a PDF—When your edits are complete, save a final version as a PDF before sending to clients or uploading to your EHR.
6. Have it reviewed—Before distributing to clients, have your final version reviewed by your licensing board, malpractice carrier, and/or a licensed attorney. HIPAA requirements and state law for ROI forms vary—this document gives you a strong, clinically grounded foundation to work from.
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