Authorization to Release Information

Authorization to Release Information
I Your Name* , the undersigned, give permission to Candice Shigemoto, CPC to release and provide to:
Client Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
The following information (check all that apply)*

My attendance in therapyMy diagnosisMy treatment planInformation relevant to coordinatingWhen treatment is terminated and whyOther (please explain in detail below)
Explain other(if chosen)
I understand that this release is valid for the extent of treatment unless revoked in writing. I further understand that I may revoke this authorization at any time in writing. If you wish this relase to be valid for a shorter term, please indicate the date it shall expire:

In consideration of this consent, I hereby relesae the above parties form any legal liability resulting from the release of this information.
Client Name*

First NameLast Name
Guardian Name*

First NameLast Name
Client/guardian signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: