Release of Information

Release of Information
Client Name:
Date of Birth:
I give my permission for Janna McGaw, LCSW, to release information to the following parties regarding my:
Dates of Service Diagnosis Treatment Plan Progress
To the following parties:
Name:
Phone Number:

Area Code Phone Number
Name:
Phone Number:

Area Code Phone Number
Name:
Phone Number:

Area Code Phone Number
I understand that this release of Information will be valid for the next 12 months, but can be revoked at any time by me in writing.
Client Name:
Date:

Month Day Year
Signature: Place curser in the box, hold left click down, and complete signature by guiding the curser with your index finger on your touch pad or with your mouse. *
Should be Empty: