Release and exchange of information



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Jennifer Hilligus, MA, NCC, LPC

of JLH Counseling, LLC

NJ Licensed Professional Counselor #37PC00429300

10E Auer Court

East Brunswick, New Jersey 08816

609-937-9702

Info@jenniferhilligus.com

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 one year from the signature date.




__________________________________

Name/Agency of Professional or School


_________________________________

Professional/School’s Telephone Number

X_______________________________

Parent or Guardian


_________________________________

Parent/Guardian Telephone number


___________________________________

Date



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