AFTC Exchange of Information Agreement This field is hidden when viewing the formGUIDThis field is hidden when viewing the formreqCodeThis field is hidden when viewing the formuserEmail This field is hidden when viewing the formSubmission Date (Admin Only) DD slash MM slash YYYY 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) DD slash MM slash YYYY Full Name(Required)Signature(Required)
