• Phone: 813.754.5555
  • Email: info@headsusa.com
  • Fax: 813.754.5552
HEADS
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  • About us
  • Programs
    • Specialized Therapeutic Foster Care
    • Behavioral Health Therapy
      • Referral Form
      • Primary Care Physician Contact
      • Consent for Treatment
      • Confidential Info Consent
      • School Permission Letter
      • Behavior Checklist
      • Psychiatric Consent
      • Telehealth Consent
      • Extension Consent
      • Confidential Info Release Consent
    • Day Program
      • Psychiatric Consent
      • Referral Form
      • Primary Care Physician Contact
      • Consent for Treatment
      • Confidential Info Consent
      • School Permission Letter
      • Behavior Checklist
      • Off Premises Consent
      • Confidential Info Release Consent
  • Handbooks
    • Client Handbook
    • Manual del Cliente
  • Telehealth
    • Telehealth Consent
    • Consentimiento De Telesalud
  • Disaster Plans
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Confidential Info Release Consent

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  • My signature below signifies that I understand that I am authorizing HEADS to release and receive the below information to and from the person/agency indicated.


  • I am not giving permission for any re-disclosure of this information other than as specified above. I request that my consent become invalid in 365 days from the date I sign it. I understand this authorization is subject to revocation at any time, unless action has already begun in good faith. I understand that my records are protected under state and federal confidentiality regulations and cannot be disclosed without any written consent unless otherwise provided for in the regulations. I understand that information held by HEADS is limited to those staff/independent contractors whose work assignments reasonably require access to my data within the purpose specified in services provided.

We want every client
to achieve their highest potential

  • Contact us
  • Call us today813.754.5555
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Contact

Email: info@headsusa.com
Phone: 813.754.5555
Fax: 813.754.5552

 

Locations

Corporate Office
1001 East Baker Street
Suite 100
Plant City, Florida 33563

Fort Myers
3049 Cleveland Avenue
Suite 290
Fort Myers, Florida 33901

Orlando
5749 Westgate Drive
Suite 200
Orlando, Florida 32853

Wildwood
901 Industrial Drive
Suite 200
Wildwood, Florida 34785

Copyright © 2020 - HEADS All rights reserved.
HEADS is an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status.
It is the policy of HEADS to comply with the requirements set forth in the Americans with Disabilities Act, Section 504 of the Rehabilitation Act as well as other applicable local and state regulations. For special accommodations or to request materials in accessible format, please contact us at (813)754-5555. If you are hearing or speech impaired please use the Florida Relay Service 1-(800) 955-8770 (Voice) or 1-(800) 955-8771 (TTY).
  • Home
  • About us
  • Programs
    • Specialized Therapeutic Foster Care
    • Behavioral Health Therapy
      • Referral Form
      • Primary Care Physician Contact
      • Consent for Treatment
      • Confidential Info Consent
      • School Permission Letter
      • Behavior Checklist
      • Psychiatric Consent
      • Telehealth Consent
      • Extension Consent
      • Confidential Info Release Consent
    • Day Program
      • Psychiatric Consent
      • Referral Form
      • Primary Care Physician Contact
      • Consent for Treatment
      • Confidential Info Consent
      • School Permission Letter
      • Behavior Checklist
      • Off Premises Consent
      • Confidential Info Release Consent
  • Handbooks
    • Client Handbook
    • Manual del Cliente
  • Telehealth
    • Telehealth Consent
    • Consentimiento De Telesalud
  • Disaster Plans
  • Careers
  • Contact us