Release of Information

Purpose

This form gives Remembering Cherubs your permission to share limited, confidential information with Avalon Healing Center. We share this information to help connect you with their counseling and support services.

Client Information

First and last name

Phone

Is it safe to call this number?

Yes

Is it safe to leave a voicemail or text message?

Yes

Best day(s) and time(s) to reach you:

Permissions

I give Remembering Cherubs permission to share the following information with Avalon Healing Center:

(Select all that apply)

My name

My phone number

The necessary information required to connect me to counseling

Acknowledgement

I understand that this release is intended solely to connect me with counseling services at Avalon Healing Center. I also understand that my information will be kept confidential and handled with care.

Client signature

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Date