AUTHORIZATION TO RELEASE CONFIDENTIAL INFORMATION
TO: __________________________________________________________
Regarding:
NAME: __________________________________________________________
HOME ADDRESS: _______________________________________________
__________________________________________________________________
BIRTHDATE: ____________________________________________________
I request that you release to ___________________________________________
all information you have of an academic, medical, psychological, and/or psychiatric nature of the above named person. I understand that he/she will keep such information confidential and will use it for professional purposes only. Please send this information to the Life Enrichment Christian Counseling Center at the Delaware address below. Thank You.
Signature: ______________________________________
Date: ________________________________
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RELEASE OF INFORMATION FORM
I ________________________________________ give permission to the counseling staff at the Life Enrichment Christian Counseling Center to be in contact with _________________________________________ regarding all
the relevant issues surrounding my counseling with the Life Enrichment Christian Counseling Center from _______________________ to__________________.
Pastor____________________________________________________
Phone #:__________________________________________________
NAME: _____________________________________
DATE: _____________________________________
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