· If I am signing as a parent or a guardian of a minor, I understand that the records released may contain references to my family and myself.
· The authorization period will continue for one year from the date below.
· I understand my right to confidentiality. I further understand that this consent form gives Jaci Varnell, LPC, permission to share confidential information about me and/or my child in the way described above.
· Release of information is voluntary, I understand I have the right to refuse Jaci Varnell, LPC ‘s, request.
· I understand I have the right to revoke this authorization in writing after signing this form.
· I understand that all information will be treated as confidential.