Psychiatric Services Psychiatric Services Compassionate, evidence-based psychiatric care tailored to your unique mental health needs. Initial Psychiatric Evaluations Medication Management Depression and Anxiety Treatment Bipolar Disorder Management Sleep Disorder Treatment ADHD and Focus Support Schizophrenia and Psychotic Disorders Management Substance Use Disorder Support Psychoeducation and Medication Counseling Collaborative Care with Primary Providers Initial Psychiatric Evaluations Medication Management Depression and Anxiety Treatment Bipolar Disorder Management Sleep Disorder Treatment ADHD and Focus Support Schizophrenia and Psychotic Disorders Management Substance Use Disorder Support Psychoeducation and Medication Counseling Psychoeducation and Medication Counseling Collaborative Care with Primary Providers Initial Psychiatric Evaluations Consult Now Medication Management Consult Now Depression and Anxiety Treatment Consult Now Bipolar Disorder Management Consult Now Sleep Disorder Treatment Consult Now ADHD and Focus Support Consult Now Schizophrenia and Psychotic Disorders Management Consult Now Substance Use Disorder Support Consult Now Psychoeducation and Medication Counseling Consult Now Collaborative Care with Primary Providers 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…