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: _____________________________________