Consent to Release Information Think LifeChange Counselor*SelectDr. Kerry L. SkinnerAlison VeazeyHannah MergistLeslie BayneKaren de GraffWalter de GraffDate* YYYY dash MM dash DD I, Client Name* First Last do hereby consent and authorize the Think LifeChange Biblical Counseling Center to Release All Pertinent Information for purposes of client care toI understand that this authorization will terminate within a year from the date on this form. Counselee Signature*Date YYYY dash MM dash DD If Under 18, Name of Parent or Guardian First Last If Under 18, Signature of Parent or GuardianCounselor Printed Name* First Last Counselor Signature*NameThis field is for validation purposes and should be left unchanged. Share this:
