This form is optional. However, it is required for those clients who wish to give me permission to speak with their health care provider regarding their coaching sessions as described below. If you decide to allow me to speak with your provider, please complete the following form prior to your coaching session. Thank you.

Authorization for the Release of Information

Please give today's date above as: MM/DD/YYYY
MM/DD/YYYY
First and Last Name including their title or credentials MD, NP, RD
Example: Thrive Medical, University Hospital

 

Thank you