Watermark Counseling Release Form

Release Form

Name

First

Last

Date of Birth

Please initial all that apply, and sign below:

A. I hereby authorize Dr. Fredric Mau and Watermark Counseling LLC to order medical or professional consultations as are considered therapeutically necessary for myself or my child under his care

B. I hereby authorize Dr. Fredric Mau and Watermark Counseling LLC to release records and other information acquired in the course of evaluation and counseling to physicians and healthcare professionals associated with my care or my child under his care.

C. I hereby authorize Dr. Fredric Mau and Watermark Counseling LLC to request any necessary records from physicians, school officials, and other healthcare professionals for myself or my child under his care.

D. I hereby authorize Dr. Fredric Mau and Watermark Counseling LLC to release records to my parent(s) or legal guardians and to discuss my case with them.

E. I hereby authorize Dr. Fredric Mau and Watermark Counseling LLC to release records and other information acquired in the course of evaluation and counseling to my school (or the school of my child under his care).

F. I hereby authorize Dr. Fredric Mau and Watermark Counseling LLC to release records to other individuals listed here.

Signature

Clear

Date