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?

If you instruct us to withhold information from someone you are or have been in an intimate relationship with during Couples, Marriage, or Family counseling, we will comply. However, if anyone in our sessions asks whether we are withholding information from them, we will confirm that we are, but we will not disclose the content of that information.

Without expressed revocation by the signee, this consent does not expire.

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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