I consent to the verbal and/or written disclosure and exchange of information between Jane V. Farley, LMHC, MHT and:
for the purpose of:
continuity of care
This release is binding beginning on TODAY'S date:
I understand that it is within my rights to terminate this release at any time.
Jane V Farley, LMHC, MFT
1779 Union Street
San Francisco, CA 94123