Release of Information - Atlanta Counseling Solutions

Licensed GA Counselor Since 1991

Release of Information

Your Name *

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I hereby give permission for Ellen Strugatch and Atlanta Counseling Solutions LLC to have full access to my psychiatric and substance abuse assessment, diagnosis, and treatment recommendations for the purpose of coordinating care and to release and exchange information with the entity (individual and/or representatives) listed below.

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Phone *

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This release is in effect until and unless revoked by phone or in writing.

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