Consent for Release and Exchange of Information with Community Mental Health Provider:
This consent will be in effect November 10, 2020.
I, {adult13}, give consent to Camp Get-A-Way to release and exchange information with my community mental health provider listed below:
Provider Name: {providerName}
Agency: {agency}
Provider Email: {providerEmail}
Provider Fax: {providerFax}
Provider Phone: {providerPhone}
_______________________
Family members covered by this consent:
- {adult13}
- {adult2143}
- {child1}
- {child2}
- {child3}
- {child4}
Printed Name: {adult13}
Relationship: {relationshipTo118}