Skip to main content

This form allows Specthrive Wellness & Behavioral Health LLC to communicate with the people, schools, or providers you list below.

It is used in both coaching and therapy work. Please complete every section, then sign and date at the bottom.

You can submit this form electronically (by typing your signature) or print it and sign by hand. Both methods have the same legal effect.

Client Information

Provider

Nancy Nyabuti, MA, LPCC. Outpatient Mental Health Therapist at Specthrive Wellness & Behavioral Health LLC.

What You Are Authorizing

I authorize Specthrive Wellness & Behavioral Health LLC to:

Share information about the client named above with the parties listed in this form.

Obtain information about the client named above from the parties listed in this form.

Parties Authorized for Release

List up to three people, schools, or organizations. If you need more space, use the notes area at the bottom of this section.

Information to Share

Check all that apply.

Purpose of Disclosure

Check all that apply.

Method of Communication

Check all that apply.

Expiration of This Authorization

This authorization will expire on whichever date you select below. If neither is selected, the authorization defaults to one year from the signature date.

Your Rights

Voluntary signing: This authorization is voluntary. Coaching and therapy services are not conditioned on signing, except where specific coordination clearly requires release of information.

Right to revoke: You may revoke this authorization at any time by submitting a written request to me. Revocation will not apply to information that was already shared based on this authorization before the revocation was received.

Limits of confidentiality: Once information is shared with a third party, it may no longer be protected by HIPAA or other privacy laws.

Sign and Submit

Sign this authorization by typing your name, your email, your relationship to the child, today's date, and checking the agreement box below. Under the federal ESIGN Act and Minnesota's Uniform Electronic Transactions Act (UETA), your typed name has the same legal effect as a handwritten signature when provided with the intent to sign. To sign on paper instead, print this form and complete the same fields by hand.

Nancy Nyabuti, MA, LPCC
Outpatient Mental Health Therapist · nancy.nyabuti@specthrivewbh.com · 612-208-6549 · specthrivewbh.com

Review your answers

Please confirm everything looks right before sending.

Client Information

Child's full name
— not provided —
Date of birth
— not provided —
Today's date
— not provided —
Parent or guardian name(s)
— not provided —

Provider

What You Are Authorizing

Parties Authorized for Release

Party 1: Name
— not provided —
Party 1: Role or organization
— not provided —
Party 1: Phone or email
— not provided —
Party 2: Name
— not provided —
Party 2: Role or organization
— not provided —
Party 2: Phone or email
— not provided —
Party 3: Name
— not provided —
Party 3: Role or organization
— not provided —
Party 3: Phone or email
— not provided —
Additional parties or notes (optional)
— not provided —

Information to Share

Educational information (IEP, 504, school performance)
— not provided —
Behavioral observations
— not provided —
General support recommendations
— not provided —
Coordination of services
— not provided —
Other (specify below)
— not provided —
If 'Other' is checked, please describe
— not provided —

Purpose of Disclosure

Coordination of care or support
— not provided —
School planning and accommodations
— not provided —
IEP or 504 support
— not provided —
General support for client functioning
— not provided —
Other (specify below)
— not provided —
If 'Other' is checked, please describe
— not provided —

Method of Communication

Phone
— not provided —
Email
— not provided —
Written reports
— not provided —

Expiration of This Authorization

One year from the signature date
— not provided —
Specific expiration date (enter below)
— not provided —
Specific expiration date
— not provided —

Your Rights

Sign and Submit

Your full name (typed signature)
— not provided —
Your email
— not provided —
Relationship to child
— not provided —
Date
— not provided —
I am providing my electronic signature on this form. By checking this box and clicking Submit, I agree my typed name above has the same legal effect as a handwritten signature, I authorize the disclosures described in this form, I intend to be bound by the terms of this document, and I have had the opportunity to print this document for my records.
— not provided —