You can print this form, fill it out, and mail the signed hardcopy to the address below, or bring it to your first appointment to fill out together.

I further permit the following named person or organization to disclose to Melanie
Fuscaldo any information that is judged likely to facilitate counseling.

  Name of person or organization _______________________________________

  Address and phone number __________________________________________

I can revoke this consent at any time except when action had already been taken.

Date _______________________________

Signature _________________________________________________________

Name printed ______________________________________________________

Address __________________________________________________________

Phone number _____________________________________________________

Email ____________________________________________________________