Consent for Release of Information (ROI)

🤝 Want Your Current Therapist to Connect with Dr. Gutierrez?
If you’d like your current therapist to share insights, background, or recommendations with Dr. Casey Gutierrez before your first session, this form is for that.

By completing it, you’re giving your therapist permission to connect directly with Dr. Gutierrez. It’s a quick way to support a smooth, coordinated transition into your care at Relateborhood Therapy.

1. PURPOSE OF THIS FORM

You are currently working with a trusted therapist or provider—someone who has supported you in your journey and wants the best for you moving forward. Sometimes, it can be helpful for your current provider to collaborate with a new therapist as part of your ongoing care.

By completing this form, you are giving your therapist (listed below) permission to speak with Dr. Casey Gutierrez, a licensed therapist with Relateborhood Therapy, so that they can share key insights, struggles, or themes that have emerged during your time together. This release supports a smoother, more connected transition into working with Dr. Gutierrez.

2. CLIENT INFORMATION

Client First Name(Required)

Client Last Name(Required)

Client Email

Date of Birth(Required)

Today’s Date(Required)

3. REFERRING THERAPIST OR PROVIDER INFORMATION (The therapist or provider you want Dr. Casey Gutierrez to connect with)

Therapist’s or Provider’s Name(Required)

First Last

Therapist’s or Provider’s Practice Name

Therapist’s or Provider’s Email(Required)

Therapist’s or Provider’s Phone(Required)

4. INFORMATION TO BE RELEASED

I authorize my current therapist or provider to share up to the following with Dr. Casey Gutierrez:(Required)

All records and information

Summary of current concerns 

History/themes from therapy 

Progress & goals 

Clinical impressions or diagnostic info 

Other (please specify below) 

Please describe what other information may be shared:

5. COMMUNICATION METHOD
I understand that Dr. Casey Gutierrez may communicate with my therapist or provider via electronic health record, phone, secure email, or another professional channel, in compliance with HIPAA.

All communication between therapists or providers will be handled with confidentiality and in full compliance with HIPAA.

6. YOUR RIGHTS

I understand that this release is voluntary. I may revoke this permission at any time in writing. This form will expire one year from today’s date unless I request an earlier expiration. All communication between therapists will be handled with confidentiality and in full compliance with HIPAA.

By typing your full name below, you are electronically signing this form. You confirm that you’ve read and understood this release of information, and you authorize Dr. Casey Gutierrez at Relateborhood to communicate with the therapist or provider listed above. You understand that this electronic signature has the same legal effect as a handwritten signature.

Signature (Type Your Full Legal Name)(Required)

Date of Signature(Required)