GUIDreqCodeuserEmail Submission Date (Admin Only) I hereby authorize (therapist's name):(Required)and (other individual or agency):(Required)to exchange written and verbal information concerning (client’s name and birth date, please print):(Required)Note: I direct my therapist not to discuss the following matters with the above-named individuals or agencies:(Required) * I understand that this authorization expires in 90 days after the date following my signature or upon ending therapy. Date Signed(Required) Full Name(Required)Signature(Required)
