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Authorization Of Disclosure Form
I, the client (or his or her parent or guardian), authorize Lisa M. Stephen, Ph.D., ACC to release oral information and written
records to:
My signature below indicates the following: I fully understand this request and authorization to release information
and records. I made this request voluntarily. I understand that I may revoke this consent at any time and no further
disclosure will occur after the date of revocation. I understand that if not revoked, this consent will expire when the
client’s case is closed. I received an oral explanation of this form
Notice of Revocation: I, the client (or his or her parent or guardian) revoke the above authorization of disclosure as
of this date: |