Client Information Release Form
I authorize Miramontes Life Center therapist/staff to provide information to:
I, Only
Myself and the person(s) below
Name
First Name
Last Name
Relation to Client
*
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Persons allowed to be contacted
*
Type of communication allowed
Verbal (calling)
Digital (email, text)
All allowed
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
*
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Should be Empty: