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Confidential Release of Information


Guided Path Counseling, LLC

641 Monroe St., Suite 111, Sheboygan Falls, WI 53085

920-627-2793 Tele 920 927 9011 Fax

I hereby consent to the disclosure of the specific information listed in this document

regarding

BY Guided Path Counseling, LLC to

Name of Client Date of Birth

Birthday
Month
Day
Year
Authorized Person's Relationship
Spouse
Parent
Friend
Employer
Attorney
Other

The initial purpose of this release is to ensure the therapist has a contact in the case of an emergency and/or

therapist’s concern with client’s mental stability. The therapist may also ask the client to sign a release to

communicate with a spouse, parent, guardian, significant other, employer, attorney, pastor, mental health

agency/therapist).

The disclosure of the following checked specific information is authorized:

This authorization will be effective from
Month
Day
Year
to
Month
Day
Year

This authorization shall expire in 1 year unless otherwise

noted. In addition, this authorization is subject to revocation at any time.


Name of person authorized to consent and relationship (Client Signature)

(parent if client is under the age of 18)

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