ACPC, PLLC
142 East Maumee Street, Suite 3
Adrian Mi 49221
Phone: 517-263-5810 Fax: 517-438-8193
Email: office@adrianpsych.com
Authorization for Release / Exchange of Information.
This release will be valid until one year from signature date. This release may be revoked by the client or guardian in writing at any time. Persons or agencies receiving information may not further release it without the informed written consent of the client.