Release of Information 
A Release of Information form must be completed before we can request or release your
records to/from another person or facility. One Release of Information form must be completed for each
transaction. For example, if you would like us to request information from your physician, one Release must be
completed. If you would like us to request information from your physician and release your records from Lifeline -
then two Release forms must be completed (one for each "leg" of the release).
Please complete the top of the Release form
(your name, name of the person or facility) and sign the form. If the Release is for your child or teen, please
have them sign as well, if they are twelve years old or older.
If you have any questions, please drop an email to jdavidson@lifelinecounseling.net.
To download a Release of Information form, click on the following link:
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