I agree to allow the release and exchange of information about me including written reports, progress notes, and telephone calls, between my therapist at Christian Counseling Centers of Indiana and the person or agency listed below.  Please consider this information confidential and share it with only those individuals designated below.

I realize and accept the responsibility for the release of this information and its potential to harm or hinder my treatment or myself in someway.  I understand that this agreement will be in effect until a period of 90 days following the end of my services with Christian Counseling Centers of Indiana.  I also understand that this agreement may be ended at any time by my written notice.

By submitting this document, you are signing the document electronically.

You agree your electronic signature is the legal equivalent of your manual or handwritten signature on the document. By returning the completed document using any device, means or action, you consent to the legally binding terms and conditions of the document. You further agree that your signature on the document is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your signature. You are also confirming that you are the patient or guardian of the patient (if the patient is under age 18) authorized to enter into the agreement as described by the document.