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    Lisa M Stephen, Ph.D., ACC

    Peak Performance Coach

     
     
  • Date Format: MM slash DD slash YYYY
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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:

  • Disclosure from: Release to:

    Lisa M. Stephen, Ph.D., ACC
    PO Box 1034,
    Jericho, VT 05465
    (802) 355-9299


  • 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

  •   Signature Printed Name Date
    Client
  • Date Format: MM slash DD slash YYYY
  • Parent/Guardian
  • Date Format: MM slash DD slash YYYY
  • Notice of Revocation: I, the client (or his or her parent or guardian) revoke the above authorization of disclosure as of this date:

  •   Signature Printed Name Date
    Client
  • Date Format: MM slash DD slash YYYY
  • Parent/Guardian
  • Date Format: MM slash DD slash YYYY
  •  

    PO Box 1034, Jericho, VT 05465 • drstephen@ignitepeakperformance.com • 802-355-9299 • www.ignitepeakperformance.com

      BUILDING THE MINDS OF CHAMPIONS
     
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