Consent for the Release/Exchange of Information
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SIGNATURE AGREEMENT: By filling out the date, providing my e-mail, and typing my name below, I recognize this electronic signature will have the same force and effect as an original signature. *
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Date *
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Last Name, First Name *
E-mail *
Gives permission to Matthew Fredin, of Integrative Counselling, to release specific information. *
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The information shared will include information regarding *
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Name of person/organization information is to be released to *
I understand this consent is valid for the service defined above. If further information/coordination is required a new release will be created. *
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