You can print this form, fill it out, and mail the signed hardcopy to the address below, or bring it to your first appointment to fill out together.
Melanie Fuscaldo LPC, NCC
1945 Pauline, Suite 10
Ann Arbor, Michigan 48103
I further permit the following named person or organization to disclose to Melanie
Fuscaldo any information that is judged likely to facilitate counseling.
Name of person or organization _______________________________________
Address and phone number __________________________________________
I can revoke this consent at any time except when action had already been taken.
Name printed ______________________________________________________
Phone number _____________________________________________________