This authorizes LOOK UP THERAPY, West Palm Beach FL, and its subsidiaries, affiliates, and clinicians, the ability to release or obtain protected health information concerning the above-named client. Protected health information may relate to my past, present or future physical or mental health condition, and the provision of my health care, or payment for my health care services. This information may be disclosed to or obtained from the following agencies (e.g., doctor’s office, school), and their employees (indicate agency name/address):