By signing this form -
I understand that I may revoke this authorization by providing a written revocation to the parties named above at any time. I also understand that any information which has been released prior to the revocation may be used for the purposes listed above.
I understand that I may have a right to inspect disclosed information at any time and that such inspection will occur in a meeting with a member of the professional staff. I acknowledge that the information to be released may include material that is protected by state and/or federal law applicable to either mental health or substance abuse or both. My signature authorizes release of all such information.