Release of Information

Client Name

First Last

I am:

Release information

I authorize Louis Carlino, MA, LPC to:

Facility/Name:

Phone

Fax Number

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Specific information to be released or obtained:

Specific information to be excluded from release (if no exclusions, leave blank):

Agreement

This information will be used to promote counseling. I understand that I may revoke this authorization at any time by giving written notice to Louis Carlino, MA, LPC. Unless I revoke this authorization prior to such time, this authorization to release/obtain information shall expire one year from the date of my signature.

Client Signature

Therapist Signature