Twin Oaks Counseling
Authorization To Exchange Information

I, the undersigned, hereby permit __________________________________________ to exchange information 

regarding my treatment with the professional,  family member, or institution listed below:

Name_____________________________________________________

Address___________________________________________________

_________________________________________________________

Phone____________________________________________________


_______________________________     
Client Name   

_________________________________
 Date

_______________________________     
Client Signature 

_________________________________                                                                                
 Parent/Legal Guardian Signature (if applicable)


_______________________________     
Counselor Signature  

__________________________________
Date

This authorization expires 30 days after the end of service.


1230 Big Bend Road, Ballwin, Missouri, 63021
636-861-1870