AUTHORIZATION FOR RELEASE OF INFORMATION

I (We) authorize ________________________________________________________________

(Facility/Provider)

_____________________________________________________________________ to release

                                                            (Address)

______________________________________________________________________________

(State specific nature of information to be disclosed)

from the clinical record of_____________________________________________ (__________)

                             (Name of client/recipient of mental health services)     (Date of birth)

to Katherine B. Therrell, LPC, PLLC, 855 Howard Gap Road, Fletcher, NC  28732 for the purposes of facilitating counseling/consultation, and/or conducting an evaluation.  I understand that I may revoke this consent at any time.  This authorization is valid until ____________________________________.

                                                                                                                  (Date)

A copy of this release shall have the same force and effect as the original.

______________________________________       ____________________________________                           

(Client Signature 12 yrs. or older)            (Date)      (Parent/Guardian Signature)                (Date)         

_________________________________     ______________________________

(Witness)                                                                  (Date)      (Relationship)

NOTICE TO RECEIVING FACILITY/THERAPIST: You may not redisclose any of this information unless the person who consented to this disclosure specifically consents to such redisclosure.