Request for Release/Exchange of Client Information
I, Type Full Name*, hereby authorize Please SelectWellspring Renewal CenterRebecca Spooner, LPC NCCLeah Payne, LPE-I, LPCSean Oakley, LCSWMichelle Ainsworth, LPCCatherine Coon, LP, RPT to release/exchange information contained in my client record to the following individual(s) and/or organization, and only under the conditions listed below:
This consent is subject to revocation at any time except to the extent that the therapist has already taken action in reliance on it. If not previously revoked, this consent will terminate
Attention: This client information release authorization form in prepared in accordance with the of authority specified in Public Act 56 of 1973. This form is in compliance with the Title 42 the Code of Federal Regulation, Part II.