RELEASE OF INFORMATION FORM Hello and welcome to my therapy practice. Please read, sign and click submit at the bottom of the page. PRINTABLE PDF Please enable JavaScript in your browser to complete this form.I/We authorize Jeff Cohen to release toany pertinent information in my records for the purpose of treatment planning and coordination; or for other purposes as listed: Release of confidential information is subject to state and federal laws. By signing this release, I acknowledge my permission to release the specified information to the individual or agency I have named. This authorization expires in one year unless otherwise stated. NameDateSignatureClear SignatureNameDateSignatureClear SignatureSubmit