AUTHORIZATION FOR RELEASE OF INFORMATION
I (We) authorize ________________________________________________________________
_____________________________________________________________________ to release
(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 ____________________________________.
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.