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.