CONSENT FOR RELEASE OF INFORMATION

I (client), ________________________,

herby authorize, (therapist) ________________________,

to release the following information ________________________________________to

_____________________.

It has been explained to me that the purpose of this information is as follows:

_____________________________________.

I understand that my records are protected under the Federal Confidentiality Regulations and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may withdraw my permission for the use of this information at any time, except to the extent that action has been taken in reliance on it (e.g. probation, etc.). It is my understanding that this consent expires automatically as described below:

Date, event or condition upon which this consent expires: ______________________________

Signature of client ________________________

Date ________________________

EUGENIA MOORE LCSW-C. 314 WYNDHURST AVE. BALTIMORE, MD. 21210 (LICENSE NO. 10973)