📋 Form 2 of 3

Client Authorization to Release & Share Information

Authorize Gomaa Life Coaching to share your information with specified persons or organizations

Client Information

Full Name *

Date of Birth

Phone

Email *

Person(s) or Organization(s) Authorized to Receive Information

At least one entry is required. You may authorize up to three parties.

Person 1 (Required)

Name *

Relationship / Organization

Phone / Email

Notes / Limitations

Person 2 (Optional)

Name

Relationship / Organization

Phone / Email

Notes / Limitations

Person 3 (Optional)

Name

Relationship / Organization

Phone / Email

Notes / Limitations

Type of Information to Be Released

General progress information Session attendance records Session notes or summaries Referral and intake information Assessment or evaluation results Other (specify in notes below)

Additional Notes / Other Details

Purpose of This Release

Purpose *

Authorization Period

Valid From

Valid Until (leave blank for indefinite)

Important Terms & Understanding

I understand that Gomaa Life Coaching & Consulting LLC provides coaching services only.

I understand that once my information is shared with the person(s) or organization(s) listed above, Gomaa Life Coaching & Consulting LLC may no longer control how that information is used or re-disclosed by them.

I understand that this authorization is voluntary. Refusing to sign this authorization will not prevent me from receiving coaching services unless the requested sharing is necessary for the specific service, arrangement, or request.

This authorization has no expiration date and remains valid indefinitely until I revoke it in writing. I may revoke this authorization at any time by sending written notice to Gomaa Life Coaching & Consulting LLC. Revocation will not affect information already shared before the written revocation is received.

Client Agreement & Signature

By signing below, I confirm that I have read and understood this authorization, had the opportunity to ask questions, and voluntarily authorize Gomaa Life Coaching & Consulting LLC to release and share my information as described above.

Full Name *

Date *

Client Signature *

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Client Authorization to Release & Share Information

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