Transformative Therapy LA Jacqueline Bocian, M.A., L.C.S.W., License #80469

I understand that California law requires each client's consent for the release of confidential information related to mental health or developmental disability. With this understanding, I hereby waive any right to confidentiality arising under California law and authorize the release of records or information, to the extent specified below.

The above information is only to be released to the following party:

at which time it shall expire and no further release of information shall be made under its terms. I understand that I can revoke this authorization at any time by giving written notice to the parties named above. This revocation will not affect information that has already been disclosed or used.

Iam signing this authorization voluntarily and treatment, payment, or my eligibility for benefits will not be affected if do not sign this authorization. I further understand that a person to whom records and information are disclosed pursuant to this authorization may not further use or disclose the medical information unless another authorization is obtained from me or unless such disclosure is specifically required or permitted by law. I hereby release the parties named above from any liabilities for release of this information. I understand that a copy of this release shall be considered as valid as the original.