Exchange of Information Agreement form Resilia Exchange of Information Agreement Este campo está oculto cuando se visualiza el formularioGUIDEste campo está oculto cuando se visualiza el formularioreqCodeEste campo está oculto cuando se visualiza el formulariouserEmail Este campo está oculto cuando se visualiza el formularioSubmission Date (Admin Only) DD barra MM barra AAAA I hereby authorize (therapist's name):(Obligatorio)and (other individual or agency):(Obligatorio)to exchange written and verbal information concerning (client’s name and birth date, please print):(Obligatorio)Note: I direct my therapist not to discuss the following matters with the above-named individuals or agencies:(Obligatorio) * I understand that this authorization expires in 90 days after the date following my signature or upon ending therapy. Date Signed(Obligatorio) DD barra MM barra AAAA Full Name(Obligatorio)Firma(Obligatorio)
