Release to Family or SO

Fill out and submit the below digital form or click here for the printable form.

  • Release of Information to a Family Member or Significant Other

  • I hereby authorize the office of Churchill Counseling Services to release the following information either over the phone or in person to any of the following persons:

  • Release to

  • I understand that I must inform Churchill Counseling Services immediately if I wish to revoke permission for any of the above individuals from receiving information from Churchill Counseling.

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