You can always press Enter⏎ to continue
Consent for Release of Information Supplement
  It is the policy of Shine Bright Counseling and Consulting, PLLC to hold all information received from or concerning clients in the strictest confidence. Shine Bright Counseling and Consulting, PLLC will not voluntarily release, obtain or exchange any information without permission of the client. This document authorizes the release of confidential information about you to the person or entity stated and for the purpose stated. If you have any questions about the form and how it is used, please ask your counselor.
6Questions
  • 1

    I,           hereby authorize            of

    Shine Bright Counseling, PLLC, and to disclose

    and/or exchange records and information regarding (name of child)           .

    Press
    Enter
  • 2
    Press
    Enter
  • 3
    Press
    Enter
  • 4
    This consent is subject to revocation by the undersigned at any time except to the extent that action has been taken in reliance hereon.
    Clear
    Press
    Enter
  • 5
    This consent is subject to revocation by the undersigned at any time except to the extent that action has been taken in reliance hereon.
    Clear
    Press
    Enter
  • 6
    Press
    Enter
  • Should be Empty:
JotForm Logo
Now create your own Jotform - It's free!Create your own Jotform
Question Label
1 of 6See AllGo Back
close