Release of Information

I, , hereby give permission for Freedom & Hope Counselling & Therapeutic Services to obtain and release information to and from the following individuals or organizations for the purpose of outpatient treatment support and planning.

Person 1 Full Name

Email Address or Phone #

Person 2 Full Name

Email Address or Phone #

Person 3 Full Name

Email Address or Phone #

Are there any exceptions, or information you do not want to share with this/these people?

Without expressed revocation, this consent expires one year from the date of signing.

I understand that I have a right to receive a copy of this authorization, and that any modification or revocation of this authorization prior to the date of expiry must be in writing.

I ASSERT THAT I HAVE READ, UNDERSTOOD, AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT:

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