SCC RELEASE OF INFORMATION
SCC RELEASE OF INFORMATION
Client Name:
1. Name
1. Name
*
First
Last
Relationship
*
2. Name
2. Name
First
Last
Relationship
I give permission for Spiritual Care Consultants of West Michigan to share information with the above named individuals or entities as it relates to my care. I will inform Spiritual Care Consultants of West Michigan if I ever wish to add or delete individuals/entities from this list.
Draw
or
Type
I understand this is a legal representation of my signature.
Clear
Full Name
I understand this is a legal representation of my signature.
Date
Date
/
MM
/
DD
YYYY
AUTHORIZATION FOR CHILD TO BE SEEN WITH SOMEONE OTHER THAN PARENT/GUARDIAN
1. Name
1. Name
First
Last
Relationship
2. Name
2. Name
First
Last
Relationship
I, being the parent or legal guardian of the above name minor, do hereby appoint the above to act in my behalf in authorizing sessions with Spiritual Care of West Michigan. This includes sharing any pertinent information during or after the session with the above named person.
Draw
or
Type
I understand this is a legal representation of my signature.
Clear
Full Name
I understand this is a legal representation of my signature.
Date
Date
/
MM
/
DD
YYYY
CONSENT FOR SPIRITUAL CARE TO SEE CHILD WITHOUT PARENT OR GUARDIAN
I give Spiritual Care Consultants of West Michigan permission to see my minor child when I am not present in the session. I understand the information collected during that time is confidential unless the items on the consent for treatment apply.
Draw
or
Type
I understand this is a legal representation of my signature.
Clear
Full Name
I understand this is a legal representation of my signature.
Date
Date
*
/
MM
/
DD
YYYY