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