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Client name ___________________________________

I understand that my records may be protected by law. If so,

I authorize _____________________________________________________________

(person, school, agency, physician, etc.)

at ____________________________________________________________________

(address, email, or phone number)

and Kathy Dickinson Gray, M.A., LPC, LMFT, OTA to exchange information for the purpose of enhancement of treatment. This information is to include medications, behavioral information and impressions, and any other pertinent information. I understand that exchanges may include and are not limited to information pertaining to risk of harm to self or others, history of abuse, mental health diagnoses, medical diagnoses, and substance use or abuse history. I also understand that this consent is revocable at any time with written notice. This signed record of consent is valid in both paper and electronic form (i.e., PDF, scanned, emailed, photo).

__________________________________________ _____________________

Client Signature (parent or guardian if applicable) Date