Exchange of Information Agreement form

Resilia Exchange of Information Agreement

GUID

reqCode

userEmail

Submission Date (Admin Only)

I hereby authorize (therapist's name):(Обов'язково)

and (other individual or agency):(Обов'язково)

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

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(Обов'язково)

Full Name(Обов'язково)

Підпис(Обов'язково)