285 E. Main St Somerville, NJ 08876
contact@ilcnj.com
(908) 707-0212
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908-707-0212 contact@ilcnj.com

Release of information

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I (client),
, hereby give permission to (therapist),
of Inner Light Counseling and Holistic Center, 285 East Main St, Somerville, NJ, 08876 to release information to and receive information from
Referring Doctor/Primary Care Doctor
Name:
Address:
Phone:
Fax:
Guidance Counselor/Other
Name:
School:
Address:
Phone:
Parent / Guardian
Name:
Address:
Phone:
Signed:
Third party witness:
Date