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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!

mentalmatterstherapy@gmail.com

Abby Hawkins

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