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Confidential Release Form

Consent For Release Of Confidential Information

I give premission for Tanya Thomas Therapy to share information with and receive information relative to the clinical aspects of my treatment in therapy.

Clients name

This authorization is signed with the understanding that my records and treatment are confidential and will not be disclosed without my written consent under illegal compulsion. Further, it is understood that I may withdraw this authorization in writing any time prior the expiration date.