Exchange of Information Agreement form

Resilia Exchange of Information Agreement

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Submission Date (Admin Only)

I hereby authorize (therapist's name):(Nécessaire)

and (other individual or agency):(Nécessaire)

to exchange written and verbal information concerning (client’s name and birth date, please print):(Nécessaire)

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(Nécessaire)

Full Name(Nécessaire)

Signature(Nécessaire)