Release of Information

Mind Body Soul Therapy, LLC

Danielle Osborne, LPC

Charleston, SC

803-450-0538

danielle.osborne.counseling@gmail.com
Release of Information
I, the undersigned, authorize Danielle Osborne, LPC and Mind Body Soul Therapy, LLC to:
Name of Person/Entity/Company
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
The information to be exchanged includes:
For the purpose of:
Client/Guardian Full Name
Signature
Should be Empty: