Consent for Release Form

Consent for private information release
I,
First Name*
Last Name*
born on
Date of Birth*

MonthDayYear
currently living at
Street Address*
City*
State*
Zip Code*
authorize CCC Counseling Services and my therapist to

disclosereceive
Select Therapist
Therapist
Information of the following description

0/150
information of the following description

tofrom
Name of person or company to be contacted
located at
Street Address
City
State
Zip Code
The purpose of the disclosure authorized herein is too

0/150
I, the undersigned, understand that the information (as indicated above) to be released from mu record is confidential and protected from disclosure. I also understand that I have right to cancel my permission to release information at any time before it is released. I also understand that my consent to release information will expire in twelve (12) months from the signature date.
Signature of Client*

Clear
Date*

MonthDayYear
Signature of Client/Guardian

Clear
Date

MonthDayYear
“Your present circumstances don’t determine where you can go, they merely determine where you start: - Nido Qubein
Should be Empty: