Arrowhead Family Counseling

                                          Administration Office
                                    N53 W30465 Arrowhead Dr.
                                           Hartland, WI 53029
                                             (262) 367-6488

Form #5B       CONSENT TO RELEASE INFORMATION
 

I ______________________________________, hereby authorize
Arrowhead Family Counseling, N53 W30465 Arrowhead Dr., Hartland, WI
to disclose to _________________________________________________________

___________________the following information from my medical records: specify
the nature or extent of information to be disclosed____________________________

____________________________________________________________________

____________________________________________________________________

The purpose or need for such disclosure is:__________________________________

____________________________________________________________________

____________________________________________________________________

This consent may be revoked at any time.  Unless expressly revoked earlier this
consent expires one year from the date of signature.
 
 
 

Signature of Client __________________________________Date_____________

Signature of Parent/Guardian or
Legal Representative_________________________________Date_____________

Signify Relationship __________________________________
 
 

--------------------------------------------------------------------------------------------
                    A STATE CERTIFIED MENTAL HEALTH CLINIC