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Release of Protected Medical Information

*Your Full Name:

*Your Email:

*Your phone number:

*Person/ Facility who you are authorizing Rise Up Counseling to release your information to:

*Their Phone Number:

*Their Email

*Relationship to you:

Additional details

*I hereby authorize Rise Up Counseling (RUC) to speak with the person or group listed above regarding my protected medical information. I also understand that I may revoke this release at any time by writing to admin@riseupcounseling.net.

Yes

*Signature

*Today's Date

Month

Day

Year

This release will become invalid one year after the date is signed.

Release of information

Our goal at Rise Up Counseling is to provide accessible, quality care for all. Our services include individual, group, couples and family counseling as well as assessments- treating grief, trauma, OCD, Neurodivergence and Veterans/First responders.

Address: 9 S Main St, Marlboro NJ

Call or text: 201-677-5801

Email: admin@riseupcounseling.net

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