• Release of Information

    Release of Information

    I hereby give consent to Martin and Muir Counseling to exchange pertinent and relevant confidential information with the individual/agency identified below. I also give consent for myself or my child to be seen in Home, school or community based settings. This release will expire 1 year from the date is signed by the client/guardian/parent.
  • Information obtained may include (check all that apply):

  • Clear
  • Should be Empty: