Release of Information Form The purpose of this form is to allow release of relevant clinical information/records to assist in client treatment. Therapist: Cara Howell, LCSW Arizona License No: LCSW-17871 Montana License No: BBH-LCSW-LIC-44290 New Mexico License No: License No. C-08738 Your Information Your Name * First Name Last Name Your Address * Your Date of Birth * You authorize Inner Path Counseling LLC to communicate with a provider to: Please choose all that apply: disclose information to receive information from exchange information with Provider Information Provider Name * First Name Last Name Provider Phone * (###) ### #### Provider Address * Digital Signature Name and Date * Thank you!
