• Authorization and Consent for the Release of Information

  • Jaci Varnell, MS, LPC-S

    www.MyMckinneyCounselor.com
  • I hereby authorize exchange of information between               Jaci Varnell, LPC-S and the following individual:

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  • Information/Records to be released in regards to the following person:

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  • ·       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.

     

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