Consent to Release Information X/TwitterThis field is for validation purposes and should be left unchanged.Think LifeChange Counselor*SelectDr. Kerry L. SkinnerAlison VeazeyHannah MergistLeslie BayneDenise LaneJessie DoddKeren NewtonBill WestDebbie HarbinMichelle SchwabAllen StevensDate* 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*Your NameYour NameYour NameYour NameDate If Under 18, Name of Parent or Guardian First Last If Under 18, Signature of Parent or GuardianYour NameYour NameYour NameYour NameCounselor Printed Name* First Last Counselor Signature*Your NameYour NameYour NameYour Name Share this:
