General Consent I authorize JP Counseling & Associates, LLC to disclose to:Name to Release to:* First Last Please enter the name of the person/entity to receive your information here.Release Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Please enter the address of the person/entity to receive your information here.Phone*The following information:* Clinical Record Dates of Service Other If you answered "other" above, please clarify below: For the purpose of:* Billing & Authorization Coordination of Care Other If you answered "other" above, please clarify below: I, the undersigned, understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it. This consent shall expire one year after the date of signature. I have read and understand the above information and give my consent.I consent to the specific release of information regarding Substance Use Disorder. I consent.Date MM slash DD slash YYYY Patient Name First Last Patient Signature*Authentication Code* Parent Name First Last Date MM slash DD slash YYYY Parent Signature (if required)Witness Name First Last Date MM slash DD slash YYYY Witness Signature*CAPTCHA