Exchange of Information Agreement form

Resilia Exchange of Information Agreement

GUID

reqCode

userEmail

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:

* 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)