Universal Release Information

Name*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
I Authorize:*
First Last
To release information contained in the records of:*
To the Individual and/or Organization:*
Reciprocal Release*
- Yes
- No
Name of Person/Organization to whom information will be released:*
Specific type of information to be released:*
The purpose and need for such information:*
This release expires on:*
Date Format: MM slash DD slash YYYY
Client or Guardian's Signature*
Date*
Date Format: MM slash DD slash YYYY
Witness Signature*
Date*
Date Format: MM slash DD slash YYYY