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I understand that I need not consent to the release of this information. However, I choose to do so willingly and voluntarily for the purpose(s) specified above.I understand and agree that a this electronic signature of this executed authorization is as valid as the original.I understand that I may revoke this authorization at any time (except to the extent that action has been taken in reliance thereon), by written, dated, communication to the Owner of Communicate to Connect Therapy, LLC.
By typing your full name/initials and date, you are signing this consent form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this consent form. You also represent that you are authorized to provide consent for the client whom this document is in regards to.
- You May Refuse to Sign This Acknowledgement -
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