Authorization to Obtain and Release Information

Authorization to Obtain and Release Information
Patient Name

First NameLast Name
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Guardian Name

First NameLast Name
I hereby authorize Let’s Talk! Therapy Center to obtain and release information from the following:
Office Name:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Signature
Should be Empty: