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.Format: (000) 000-0000.
Email
example@example.com
Information to be released:

Other
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.
Date

MonthDayYear
Date
Signature
Guardian Signature (if under age 18)
Should be Empty:

Consent to release information