Release and exchange of information

Jennifer Hilligus, MA, NCC, LPC

of JLH Counseling, LLC

NJ Licensed Professional Counselor #37PC00429300

5F Auer Court

East Brunswick, New Jersey 08816

609-937-9702

[e-mail]

www.jenniferhilligus.com

RELEASE AND EXCHANGE OF INFORMATION

I, __________________________, hereby authorize the release and exchange of all information concerning my treatment and functioning to/from Jennifer Hilligus, Licensed Professional Counselor to _______________________. This authorization will expire at the end of the calendar year.

__________________________________

Name/Agency of Professional or School

_________________________________

Professional/School’s Telephone Number

X_______________________________

Parent or Guardian

_________________________________

Parent/Guardian Telephone number

___________________________________

Date