INTAKE6-AuthROI-Copy1
Online Authorization to Release/Receive Information
*
mandatory fields
Recipient Role/Description
Client/Parent/Guardian
Your First Name
*
Your Last Name
*
Your Email Address
*
Verify Your Email Address
*
Leave this box checked if you do NOT know your clinician's name.
First Name
*
Last Name
*
Email
*
Comments for Recipient
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