I understand that I have a right to meet with my clinician to inspect my mental health records and any information that will be disclosed. I further understand that this information cannot be re-disclosed without my express authorization. I
understand that I may revoke this consent at any time except to the extent that action has already been taken.
This authorization shall remain valid for one year from the date of signature unless revoked in writing by the client's
guardian or conservator. This authorization releases Families First Therapy, LLC from any and all legal liability that may arise as a result of compliance with this release of information request.
TO THE RECEIVING PARTY OF THE INFORMATION: This information has been disclosed to you for the SOLE PURPOSE
STATED IN THIS CONSENT. Any other use of this information without the express written consent of the client is
prohibited. These records may be protected by Federal Regulation (42 CFR Part 2
My signature below attests to the fact that I have read this form, understand its content and request that the above information be released as specified.