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L AUTHORIZATION TO DISCLOSE INFORMATION Name of Child/Client: Last First Date of Birth Age I authorize the following to disclose information regarding the child/client: Lacey Fisher, LPC, NCC, RPT
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Start by writing the first name of the childclient in the designated field.
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If the childclient has a middle name, include it in the appropriate box.
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Finally, provide the last name of the childclient in the corresponding section.
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What is name of childclient?
The name of the childclient is the legal name of the minor individual the form is being filed for.
Who is required to file name of childclient?
The legal guardian or parent of the childclient is required to file the name of childclient.
How to fill out name of childclient?
The name of the childclient should be filled out by typing or handwriting the full legal name of the minor.
What is the purpose of name of childclient?
The purpose of the name of childclient is to identify the specific minor individual the form is related to.
What information must be reported on name of childclient?
The only information required to be reported on the name of childclient is the full legal name of the minor individual.
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