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Roi Form

I hereby authorize and direct (enter name of clinician):
This authorization expires once treatment concludes or when the client requests that it be removed, whichever comes sooner. By signing this authorization form: I understand that my records contain information regarding my mental health. I give specific permission for this information to be released. I understand that my records are protected under State and Federal law and cannot be disclosed without my written consent unless otherwise provided for by law.
Clear Signature