Authorization to Obtain and Release Information
Patient Name
First Name
Last Name
Birthdate
-
Month
-
Day
Year
Date
Parent/Guardian Name
First Name
Last 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
City
State / Province
Postal / Zip Code
Parent/Guardian Signature
Submit
Should be Empty: