I, Print your name , authorize Athlete's Academy to release the following protected health information pertaining to myself to Kennesaw State University:

1. Name
2. Dates of session attendance
3. Referrals to other sources and reason for referral
4. Other Specify your request here   

for the purpose of:

1. Coordinating treatment efforts
2. Other Specify your request here   

This consent will automatically expire one (1) year after the date of my signature as it appears below.

I understand that I have the right to refuse to sign this form and that I may revoke my consent at any time by indicating so in writing. If I do this, it will prevent any disclosures after the date received but cannot change the fact that some information may have been shared before that date. I hereby release Athlete's Academy from all legal responsibility or liability that may arise from this authorization.