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By signing this form, I consent that Jo Dakin may release information to a specific individual or agency if it has been determined that a vulnerable person (child or elder) is at risk; if I, as a client, am in imminent danger to myself or others; or if a subpoena of records has been requested.


I also understand that, at any time, Jo Dakin may discuss aspects of my case with other colleagues keeping my full name and identity completely confidential always unless I have given permission otherwise.




Full Name:    _________________________    Signature: _____________________________

Date:             _________________________

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