Jenny Russell Release of Information

Release of Information
I, First Name Last Name , consent to allow Jennifer Russell, LPC, RPT to disclose and/or obtain information regarding my treatment with the following:
Name of Person and/or Institution
Contact information
Description of information to be disclosed:

Other (Specify)
This consent will automatically expire one (1) year after the date of my signature as it appears below, or on the following earlier date, condition, or event: blank.
I understand I have the right to refuse to sign this form and my refusal will not affect my treatment.

I may revoke my consent at any time by submitting a written request to Jennifer Russell, LPC, RPT.

My signature below confirms that I have read, understand, agree to, and consent to the information stated in the Release of Information form. I have also had the opportunity to ask questions about and
Client Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Client Name (Printed)
D.O.B
(For Minors Only) I declare that I am the legal guardian and/or managing conservator of First Name Last Name and grant the release of information.
Parent/Guardian Signature
Parent/Guardian Name (Printed)
Relationship to Client
Should be Empty: