Authorization for Release of Information

Authorization for Release of Information

CONFIDENTIAL
Clients Name

First Name Middle Name Last Name
Is Client under age 14? All legal guardians must sign a release form. *

Yes No
Clients Address

Street Address

Street Address Line 2

City State

Zip Code
Client's Phone Number
Client's Birth Date

Month Day Year
I give full authorization to release confidential client information to the following:
Address

Street Address

Street Address Line 2

City State

Zip Code
Phone Number
Fax Number
Email
example@example.com
Client Signature

Clear
Parent/Guardian Name if child under age 14
Parent/Guardian Signature if child is under age 14

Clear
Parent/Guardian Name if child under age 14
Parent/Guardian Signature if child is under age 14

Clear
Should be Empty: