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Directory Results for Client: Housing and Residence Life to Client: ID: AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INATION Client Name: DOB I hereby give permission for Counseling Alliance of VA, LLC and their clinicians to exchange information with: Name: Phone #: Address: FAX #: The information

Client: Housing and Residence Life
CLIENT: I
CLIENT: ID# DATE: THPST:
Client: ID: AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INATION Client Name: DOB I hereby give permission for Counseling Alliance of VA, LLC and their clinicians to exchange information with: Name: Phone #: Address: FAX #: The information