AUTHORIZATION FOR RELEASE OF INFORMATION OR RECORDS

Hicks Counseling Services
Beverly Hicks, M.Ed.
NC: LCMHC, CCS, CADC
TX: LMFT, LCDC

Mailing: 9650 Strickland Rd. Suite 103-424
Raleigh, NC 27615

Office: 919.904.4257
Fax: 866.594.1848
www.hickscounseling.com

Hicks Counseling Services, PLLC.

Beverly Hicks, M.Ed.NC: LCMHC, CCS, CADCTX: LMFT, LCDC
AUTHORIZATION FOR RELEASE OF INFORMATION OR RECORDS
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I hereby give permission for Beverly Hicks, M.Ed., LCMHC to disclose clinical information and/or obtain information from;

Family MemberDoctorLawyerHospitalSchool
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I hereby give permission for Beverly Hicks, M.Ed., LCMHC to disclose clinical information and/or obtain information from;

Family MemberDoctorLawyerHospitalSchool
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First NameLast Name
Phone:
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Street Address

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Postal / Zip Code

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I may revoke this consent at any time with a written request. This authorization will expire one year after the date of this document.
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