Trinity Release Form – Trinity Behavioral Health

Information Release Form

Please complete and submit the following information form.

Information & Release

Select the course you are taking with Trinity Behavioral Health.

Starting Date (Today) of the course you are taking.

First Name

Last Name

Email address

Age

Sex

Address

Street Name and number

Apartment or Unit number

City

State

Zip Code

Country

Contact Numbers

Please list your contact phone numbers

County or City of Court Proceedings

Your Attorney's Name (if applicable)

Judge's Name (if applicable)

Release Of Information

I understand that information may be exchanged with the staff of Trinity Behavioral Health, LLC - also known as, Trinity Behavioral Health Education Institute (TBHEI).

I understand that information can be exchanged with the representatives of the Courts, the Probation Department, the Department of Children Services, or Local Shelters, as well as in any emergency situations in need of immediate attention.

I understand that my records are protected under certain legal and ethical regulations and cannot be released without my consent or unless subpoenaed by a court of law.

Please check / click the box below to indicate that you have read and agree with the Release Of Information provided above.

YES I agree with the Release Of Information Terms