Life Enrichment Christian Counseling Center
Please fill out and forward to your counselor

 
 
 

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:___________________________________________








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: _____________________________________________________