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I understand that I may withdraw or revoke my permission at any time by notifying Kirkland Clinical Associates LLC/Dan Kirkland MS LPC-S in writing. Kirkland Clinical Associates LLC/Dan Kirkland MS LPC-S Authorization for Release of Records or Information I hereby give permission to Name Social or B-day with about My entire record or specified information limited to. I may revoke this consent at any time by writing to the holder of the information except to the extent that action has been...

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