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: _____________________________