Release of Information

I hereby authorize SpringSource Psychological Center, PLLC to release to and obtain information from: (this should be someone like a medical doctor/psychiatrist/dietitian or emergency contact, etc.)

    I have had explained to me and fully understand this request/authorization to release/obtain records and information, including the nature of the records, their contents, and the likely consequences and implications of their release. This request is entirely voluntary on my part. I understand that I may take back this consent at any time, except to the extent that action based on this consent has already been taken.
    This entry acts as a client signature.
    This form has been modified from The Paper Office. Copyright 2008 by Edward L. Zuckerman.