Letter Request form - Shoreline Counseling, LLC. 
Email *
Disclaimer: Submitting a letter request to Shoreline Counseling does not guarantee approval. Each request is subject to our discretion and adherence to our policies, procedures, and scope of practice. Letter submissions will be processed within 30 days of receipt.
Name and Date of Birth of client: *
Name of person making request, and relationship to client. If self, write self.  *
Clinician name: *
Name, address and phone number of agency or organization that this letter will be released to. Letters can not be addressed to "To Whom it May Concern." *
Reason for letter request. Please add any information to help us better understand your request.  *
Timeline for letter completion of letter if applicable. 
I understand that if this letter is approved that I will need to sign a release of information so that this letter can be sent directly to the person, agency or organization it is addressed to.  *
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