Gomaa Life Coaching & Consulting LLC
Client Authorization to Release & Share Information
No Expiration Date — Valid Until Revoked in Writing
Client Information
Client Full Name *
Date of Birth
Phone
Email *
Address
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
Authorization
I authorize Gomaa Life Coaching & Consulting LLC to release, discuss, disclose, share, and exchange information about me and my participation in coaching services with the person(s) or organization(s) listed above.
This authorization includes all information in the possession of Gomaa Life Coaching & Consulting LLC related to me, including intake information, forms, coaching goals, session-related notes, progress updates, scheduling information, payment or administrative information, written or electronic communications, concerns discussed during coaching, and information provided by me or created in connection with coaching services, unless I write specific limitations below.
This authorization includes communication by verbal discussion, phone, video, text message, email, written correspondence, electronic communication, or any other reasonable method.
Specific Limitations or Excluded Information (if any)
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.
Client Printed Name *
Email Address *
Date *
Client Signature *
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