Stacy Finch, RCC
Life Coach and British Columbia Registered Clinical Counsellor #20192
www.stacyfinch.com
stacy@stacyfinch.com
Client Consent for Release of information
I authorize Stacy Finch, RCC, CCC to disclose and/or obtain information related to my treatment with any healthcare provider, mental health professional, educational institution, or other relevant individual/agency involved in my care, for the purpose of coordination of treatment and support
I understand that:
- This authorization allows Stacy Finch, RCC, CCC, to communicate with any provider or agency as needed, except those I specifically exclude below.
- I may limit the type of information shared by indicating restrictions below.
- This authorization is voluntary and I may revoke it at any time by providing written notice.
- Revocation will not apply to any information already disclosed in reliance on this authorization.
- This release does not allow providers to share my information with third parties without my explicit consent.
- This consent will remain valid for one year from the date of signing unless revoked earlier.