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Authorization to Release Information

South Shore Counseling

Authorization to Release Information

I hereby authorize South Shore Counseling to release information from my clinical record to the person/organization specified below.

Release Information To

This authorization will expire on the date specified above or one year from today, whichever comes first.

Signatures

Client Signature

Client signature required

Guardian Information (if applicable)

N91W17194 Appleton Ave, Suite 204, Menomonee Falls, WI 53051

9735 W St. Martin's Rd, Franklin, WI 53132

P 414-502-7780 | W www.southshorecounseling.org