Release of Information Form

    Date:

    I,
    Client name:

    authorize my therapist, Simcha Shtull (LH-60288715), 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.

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