• Skip to main content
  • Skip to header right navigation
  • Skip to site footer
  • Home
  • About Denise
  • Forms
  • Fees & Policies
  • Online Classes
  • Upcoming Events
  • Contact
  • 713-823-4001
Denise O’Doherty

Denise O’Doherty

Licensed Professional Counselor, Licensed Marriage and Family Therapist, Drug and Alcohol Counselor, Registered Nurse

  • Relationship Counseling
    • Couples Therapy
    • Marriage Counseling & Family Therapy
    • Premarital Counseling
    • Domestic Abuse Counseling
    • IMAGO Relationship Therapy
  • Substance Abuse
    • Alcohol & Drug Addiction
    • SALCE Evaluations
  • LGBTQ+
    • Lesbian Therapy
    • LGBTQ+ Couples Therapy
  • Other Areas of Practice
    • Anxiety/Depression
    • BiPolar Disorder
    • Codependency/Personal Boundaries
    • Grief Counseling / Grief Therapy
    • Love Addiction/Love Avoidance
    • Overcoming Shame /Increasing Self-Esteem
    • Post Traumatic Stress Disorder
    • Dissociative Disorders
  • Gender Identity
    • Parents of Transgender Children
    • Gender Dysphoria
    • Cross-Dressing
    • Adult Children of Transgender Parents
  • Articles

Authorization for the Release of Confidential Information

"*" indicates required fields

By completing this form, I authorize Denise O’Doherty LPC MSN to exchange verbal and/or written diagnostic, referral and treatment information about me with the person(s) indicated below.
Your Name*
Name of party to whom information is being released*
Additional Name of party to whom information is being released (if applicable)
Additional Name of party to whom information is being released (if applicable)
Specific information to be released regarding:
Check all that apply
The purpose of this exchange is to:
Check all that apply

I understand that my records and information are highly confidential and are protected under federal, state and local laws, rules and regulations as well as codes of ethics governing the practice of counseling and psychotherapy and cannot be disclosed without my written consent.

I hereby give my written consent to Denise O’Doherty LPC, MSN to disclose the information indicated above for the purposes noted above. I understand that this consent expires 6 months after my last date of service and that I may revoke this consent at any time except to the extent that action has been taken in reliance on it (probation, parole, etc.). I further understand that once I release information to the party listed above that Denise O’Doherty LPC MSN can not ensure the confidentiality of that released material. A photographic copy of this authorization shall be considered as valid as the original.

Clear Signature
This field is for validation purposes and should be left unchanged.
  • Facebook
  • Twitter
  • Google
  • YouTube
  • LinkedIn

Houston, TX 77019 | 713-823-4001 | Sitemap | Privacy Policy

Copyright © 2025 · All Rights Reserved · Maintained by Levy Marketing