I,{yourName}, hereby authorize {counselorplease} to release and/or exchange information with {nameOf}. Authorization is valid for seven years from signuature date, unless otherwise indicated, or until treatment is termined. A photocopy, email, or fax of this original shall be as valid as the original.
The information is otherwise confidential, and its use is limited to the treatment of {clientName}.
Solace Counseling and Anxiety Center1058 Asher Way, Ste 400 Tyler | 1828 ESE Loop 323, 3rd Floor Tyler | 313 E. Charnwood Tyler solacecounselingstaff@gmail.com | Office: 903-952-3757 | Fax: 903-561-8373