Release of Information - Client Self-Service

Use this form to document your consent for our communication of your confidential information with other individuals or agencies.

  • Our electronic intake and consent forms utilize email communication for transmission of your information.

    Email and text messaging, while efficient, are relatively insecure.

    Please be informed that these methods, in the typical form, are not confidential means of communication. While we use encryption to secure the contents of emails sent between our webservers and your inbox, there is still a chance these communications, which may contain confidential information, could be intercepted.

    The kind the parties that may intercept these messages include, but are not limited to:

    • People in your home or other environments who can access your phone, computer, or other devices that you use to read and write messages.
    • Your employer, if you use work email to communicate with any employee of ANOD Inc.
    • Third parties on the Internet such as server administrators and others who monitor Internet traffic.

    We offer electronic documentation for convenience and to remove barriers to care. It is not a requirement to receive services. If you'd prefer not to utilize electronic documentation, please do not complete this form, and call us to discuss alternative methods for completing this paperwork. 

    By proceeding past this page, and clicking the box below, you are acknowledging the risks explained above and agreeing to utilize our electronic forms and email communication.



  • MM slash DD slash YYYY
  • This may be the client, or the parent/guardian.
  • This may be the client or the parent/guardian. A signed copy of this authorization will be sent to this email.

  • Agency/Person for whom the release is being signed

  • Required if "business/agency" is selected above.
  • Required if "personal contact" is selected above.

  • Nature & Purpose of Disclosure

  • The most common options are pre-selected. Please check/uncheck options to match your preference.

  • Expiration of Authorization

  • MM slash DD slash YYYY
  • Signature:

  • This field is for validation purposes and should be left unchanged.