Release of Information

I, the below signed, 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.

1st. Person's First and Last Name

2nd Person's First and Last Name

3rd Person's First and Last Name

Any exceptions—information you don’t want shared with these individuals? PLEASE NOTE: If you ask us to withhold info from a former intimate partner (in relational Counselling) we will do so. However, If asked, we’ll confirm withholding, not content.

Your Full legal Name

Date

Year

Month

Day

I ASSERT THAT I HAVE READ, UNDERSTOOD, AND AGREE TO AOO OF THE ITEMS CONTAINED IN THIS DOCUMENT. Place your Signature here:

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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.