JIREH COUNSELING CENTER

Release and Signature Forms
SIGNATURE ON FILE
I hereby authorize the release of pertinent information acquired during my evaluation and treatment to my insurance company.
Signature (Client or Legal Guardian)

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Date

MonthDayYear
Date
I hereby authorize that payments be made directly to the signed clinician, realizing I am responsible to pay any services not covered.
Signature (Client or Legal Guardian)

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Date

MonthDayYear
Date
Provider
Should be Empty:

Release and Signature Forms