RELEASE OF INFORMATION

I consent to the verbal and/or written disclosure and exchange of information between Jane V. Farley, LMHC, MHT and:

Address:

City:

State:       ZIP:


Telephone:

Email:


for the purpose of:

diagnostic assessment

treatment planning

continuity of care

other


This release is binding beginning on TODAY'S date:

I understand that it is within my rights to terminate this release at any time.


 

Client Signature

Date  


 

Parent/Guardian Signature (if needed)

Date