Consent to Release Information

Consent to release information
Name*

First NameLast Name
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
I, hereby grant my consent for Allegro Counselling to release the following information to:
Recipient

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Information to be released:

Counselling session informationAssessment informationTreatment planOther
Exceptions / Restrictions if any:
Potential Risks and Limits:

I understand that the information disclosed may include sensitive and private details about my mental health, which may be subject to legal or other restrictions regarding its use or re-disclosure. I acknowledge that Allegro Counselling will make reasonable efforts to ensure the confidentiality of the released information, but cannot guarantee absolute security.

Revocation of Consent:

I understand that I have the right to revoke this consent at any time by providing written notice to Allegro Counselling. I understand that such revocation will not apply to information that has already been released in reliance on this consent.
I consent to the release of personal and confidential information within the specified parameters, listed herein, and I understand that I may revoke this consent at any time, by sending written notice to info@allegrocounselling.com
Date

MonthDayYear
Date
Signature*

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Guardian Signature (if under age 18)

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Should be Empty:

Consent to release information