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hereby authorize Sharon von Lentz, Psy.D / Crossroads Counseling to share and exchange psychotherapeutic health information from my case as necessary for treatment and for the continuity and coordination of care. I understand that my protected health information may be used and disclosed to carry out treatment, for payment of services, or for health care operations to improve the quality of care by Sharon von Lentz, Psy.D./Crossroads Counseling I acknowledge receipt of the Sharon von Lentz, Psy.D/ Crossroads Counseling Notice of Privacy Practices and I understand that I have the right to review the Notice before signing this consent. I understand that any changes in the Notice are available to me upon request. I understand that this authorization is in effect for one calendar year from the date on this form. I understand that I have the right to request in writing that Sharon von Lentz, Psy.D / Crossroads Counseling restrict how my protected health information is used to carry out treatment, payment, or health care operations. I understand that Sharon von Lentz, Psy.D / Crossroads Counseling is not required to comply with my request.

This form is authorized for 3 years from the date of signing