This is a consent for release of information (hereinafter referred to as the "Release of Information") about:

I authorize, Melissa Paramo/Paramo Therapy Group to release or obtain (select below) 

This Release of Information is not automatically renewable.  it expires automatically at the end of the period specified unless revoked in writing sooner.

I understand I have the right to see this information at any time. I understand that I can revoke this consent in writing to both the person giving and the person receiving the information.  Any information already released may be used as stated on the consent.  By my signature below, I affirm that I have read this release or it has been read to me, and I understand its content.

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