Release of Information Form

Date:

I,
Client name:

authorize my therapist, Simcha Shtull (MHCA.MC.60137436), to release my counseling and/or psychotherapy records as well as any other information concerning my mental and physical health, including medical and mental health history to:

Name:

Email:

Address:

Client Signature

Name:

Email:

Social Security #:

Date of Birth:

Telephone #:

By clicking the "Yes" box, I attest that I agree to the release of information to the above individual.
 Yes

Please type in text below: