Consent to Release of Information

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

  • DD dash MM dash YYYY
  • Coach/Therapist Information

  • Information will be released to: Hope Redefined 9813 Crestline Drive Knoxville, TN 37922 865-214-7778 Relationship to Client is: Coach, Group Facilitator, and/or Retreat Facilitator
  • Please check all areas that your info can be released in case there are different support persons responsible for one of your services.
  • 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.
  • MM slash DD slash YYYY

Contact Us

I'm interested in: