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Release of Information
Ray of Hope Child Therapy Services Inc
533 Airport Blvd. #400
Burlingame, CA 94010
877-758-7257
contact@turajohnsonmft.com
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Email
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Name
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Date of Birth
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I authorize Ray of Hope Child Therapy Services Inc to disclose my email address to Lyra Health for the purpose to complete survey and outcomes. This authorization will expire one year from today's date.
I understand and consent to the above statement
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Today's Date
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By typing my full name, I am authorizing Ray of Hope Child Therapy Services to provide only my email address.
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The parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
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