Authorization for Release of Confidential Information

Authorization for Release of Confidential Information

  • Add a new row
    Please add each name authorizing the release of information
  • To exchange information/records with Joshua Coleman, Ph.D., with the knowledge that such contact discloses my services. The disclosure of information/records is required for evaluation, treatment planning, or for the following purpose:
  • This consent is subject to revocation by the undersigned at any time. If not earlier revoked, this consent expires one year after the signature date.