Consent form

I _____________________________ hereby authorize _____________________________ (therapist)

of _____________________________ (city/state) to release any and all information contained

in the record of _____________________________ (patient’s name) to Evergreen Psychotherapy Center for professional use only.

This consent will expire on _____________________________ (mm/dd/yyyy).

Signed: _____________________________

Relationship to patient: _____________________________ (parent, self, etc.)

Witness: _____________________________

Date: _____________________________