Release Form

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Guard Their Hearts Information Release

Client Full Name

Birthday

Month

Day

Year

I hereby authorize the release of information and/or psychological reports regarding the above named person TO / FROM: Aviva Kohl, LCSW-R 845.269.5008 16 Wits End Spring Valley, NY 10977 TO / FROM:

Name

Address

Relationship to Client

Contact information: (phone, fax, email)

Limitation of information: (Please initial)

I hereby limit the information shared to the following only:__________________________

Signature

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Date

Month

Day

Year

Printed name(signed by):

Address

Release Form