Release of Information

I hereby authorize Affiliated Counseling Services to release and recieve information from the records of: *

First

Last

Date of Birth *

Records to be released to/received from: *

Please include name and relevant contact information (phone number, fax number, address, email etc...)

The purpose of this release: *

Other purpose:

Information to be released (Select all that apply) *

Other Information to be released:

Please indicate the date of the earliest record you would like us to release *

Indicate the specific range of dates you would like us to release (if applicable)

Effective Date *

This consent will remain in effect until one year following 'effective date', or until the date indicated below:

I understand that this consent is reversible upon written request, except to the extent that action has been taken (e.g. information has already been released in accordance with this authorization).

Signature

Comment

Therapy for Individuals,
Couples, and Families

814-835-7043

1444 W. 38th Street Erie, PA 16508

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