ACPC, PLLC142 East Maumee Street, Suite 3Adrian Mi 49221Phone: 517-263-5810 Fax: 517-438-8193Email: info@adrianpsych.com

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.
ACPC
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142 EAST MAUMEE STREET SUITE 3 ADRIAN MI 49221
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to release/exchange the following written and verbal information concerning:
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Initial AssessmentADD/ADHDPsychiatricSubstance Abuse/AlcoholBehavioralMedicationsLab WorkProgress NotesTreatment ConcernsBariatric ConcernsContinued Treatment
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.
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