Consent to Release of Information

This form is a consent to release information between two support professionals on the behalf(s) of mutual client(s). Client will receive a copy of this agreement upon submission. If you have any questions prior to submitting please contact Lyschel Burket at LyschelBurket@hoperedefined.org.

Date*
DD dash MM dash YYYY
Date of Birth*
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Coach/Therapist Information
Name
First Last
Name of Practice
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email
Information will be released to: Hope Redefined 9813 Crestline Drive Knoxville, TN 37922 865-214-7778 LyschelBurket@Hope-Redefined.com Relationship to Client is: Coach, Group Facilitator, and/or Retreat Facilitator
Please select the support professional your information can be released to:*
Please check all areas that your info can be released in case there are different support persons responsible for one of your services.
What can be released between these two parties?*
Why is information being released?*
This authorization lasts for one year after the date of submission unless otherwise noted by the client in this form. This authorization may be canceled in writing at any time. An email of this authorization will be treated in the same way as an original. By checking the box below and inputting your name this holds the same authorization as your signature. Your agreement indicates that you have read and understand this form, and authorize release of your information as described above.
*
I agree to the contents of this form and agree to the release of information as stated in this agreement between Hope Redefined and my professional practitioner
Date*
MM slash DD slash YYYY
Client Name (Signature)*
Additional Notes:

Consent to Release of Information

Consent to Release of Information

Coach/Therapist Information

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