This form is to be completed and signed by clients or parent/guardian, if client is a minor. A signed form authorizes the release of requested information from your clinical record to an individual or facility.
I understand that this material is confidential and will become part of my records with the authorized person or
agency, and that it will not be shared with other agencies without written permission. However, I also understand that records are subject to review by a person’s agency supervisor.
Please forward information to:
Brave Soul Counseling Services
445 Broadway Avenue, Suite A
St. Paul Park, MN 55071
This authorization is valid for one year after the date signed unless indicated otherwise. This authorization may be canceled in writing at any time. I understand that I may refuse to sign this authorization and that refusal to sign will not affect treatment.
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