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. Yes Please type in text below: To use CAPTCHA, you need Really Simple CAPTCHA plugin installed.