Mental Health Coaching Mental Health Coaching Supportive, action-oriented guidance to help you reclaim your strength and step into purpose. Life Transitions & Goal Setting Self-Esteem and Confidence Coaching Burnout and Stress Management Mindfulness and Emotional Regulation Training Inner Child and Shadow Work Support Coaching for Empaths and Highly Sensitive People Spiritual Growth & Alignment Coaching Journaling, Affirmations, and Gratitude Practices Tools for Rewiring Limiting Beliefs Guided Visualization and Meditation Sessions Life Transitions & Goal Setting Self-Esteem and Confidence Coaching Burnout and Stress Management Mindfulness and Emotional Regulation Training Inner Child and Shadow Work Support Coaching for Empaths and Highly Sensitive People Spiritual Growth & Alignment Coaching Journaling, Affirmations, and Gratitude Practices Tools for Rewiring Limiting Beliefs Guided Visualization and Meditation Sessions Life Transitions & Goal Setting Consult Now Self-Esteem and Confidence Coaching Consult Now Burnout and Stress Management Consult Now Mindfulness and Emotional Regulation Training Consult Now Inner Child and Shadow Work Support Consult Now Coaching for Empaths and Highly Sensitive People Consult Now Spiritual Growth & Alignment Coaching Consult Now Journaling, Affirmations, and Gratitude Practices Consult Now Tools for Rewiring Limiting Beliefs Consult Now Guided Visualization and Meditation Sessions Consult Now 1. Client InformationFull NameDate of Birth MM slash DD slash YYYY Phone Number2. I authorize Mental Vitality Health PLLC to: Release information to Obtain information from Exchange information with 3. Recipient of InformationName/FacilityPhoneFaxAddress4. Information to Be Disclosed (check all that apply) Psychiatric evaluation Medication list Progress notes Treatment plan Diagnosis Medical history Lab results Other Other5. Purpose of Disclosure (check all that apply) Coordination of care Legal proceedings Insurance/benefits Personal use School/employment Other Other6. Authorization Terms I understand that this authorization is voluntary and that services will not be impacted if I choose not to sign. I understand that this authorization will remain in effect for one year from the date signed unless revoked earlier in writing. I understand I can revoke this authorization at any time in writing. Revocation does not apply to information already released in good faith. I understand that information disclosed may no longer be protected by HIPAA once it is released to a third party.7. Client Signature By signing below, I acknowledge that I have read and understand this authorization and voluntarily agree to the release of information as specified.Client SignatureDate MM slash DD slash YYYY Parent/Guardian (if minor)Relationship {{#message}}{{{message}}}{{/message}}{{^message}}Your submission failed. The server responded with {{status_text}} (code {{status_code}}). Please contact the developer of this form processor to improve this message. Learn More{{/message}}{{#message}}{{{message}}}{{/message}}{{^message}}It appears your submission was successful. Even though the server responded OK, it is possible the submission was not processed. Please contact the developer of this form processor to improve this message. Learn More{{/message}}Submitting…