Below is the HIPPA Disclosure. Please print out for your information.
Client HIPPA Disclosure Hippa Form
If you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), complete this form to authorize release of psychotherapy information:
Release of Information Authorization to Disclose Information Form
Note: To download Adobe Acrobat Reader for free, click here.
Melonie Gale, MA,
LCPC, LMFT, LPCC, LMHC, NCC
Psychotherapy & Counseling for Adult Individuals & Couples