Release of Information

Release of Information

Brighter Health Counseling
Client Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Name of person to receive information*

First NameLast Name
What information would you like released to the person listed above?*
Date this Release Authorization Expires*

MonthDayYear
Date
With my signature below, I authorize Brighter Health Counseling to discuss, release, or obtain information with the person listed above. I understand that Brighter Health Counseling is not liable for the records after they have been passed along to the person listed above.
Client Signature*

Clear
Should be Empty: