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ABBY HAWKINS-

Mental Matters Therapy

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Release of Information

Please fill out the following form
in order to have the provider Abby Hawkins LPC release information to listed recipient

Client's Full Name:

If client is a dependent, full name of legal guardian:

Email

Date of Birth

Select "Yes" or "No" to confirming this informtion will be allowed to be shared from current date to 90 days in the future. *

No

Yes

Select yes or no to allowing said provider to release information: *

No

Yes

Provide name of facility or persons, address, email and phone number as well as information you are comfortable to release listed below:

Initials

I declare that the info I’ve provided is accurate & complete

Your Signature

Thanks for submitting!

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