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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
1935 Pauline, Suite 200
Ann Arbor, Michigan 48103
(734) 788-7806

Release of Information

I ___________________________________________________________
give my permission to Melanie Fuscaldo, Licensed Professional Counselor to discuss
relevant information from any counseling session or sessions with the following named
person or organization for the purpose of furthering counseling goals.

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.

Date _______________________________

Signature _________________________________________________________

Name printed ______________________________________________________

Address __________________________________________________________

Phone number _____________________________________________________

Email ____________________________________________________________