Release of Information *

I authorize Libby Kinkead, MA to discuss the following with the above provider, minister, or life coach. I choose to release Libby and the above person to communicate in my best interest within the limits of keeping my personal information as confidential as possible out of respect and care for me. Please select as many as apply:

Summary of sessions, progress, or recommendations

Financial Information

Collaboration with other provider, minister, life coach

Other (Please specify below)

Authorization *

I certify that this request has been made voluntarily. I understand that I may revoke this authorization at any time by written notice to Libby Kinkead, MA except to the extent that action has already been taken to comply with it. Without my express revocation, this authorization will automatically expire upon satisfaction of the need for disclosure but, in any event, six months from the date my sessions are terminated. By typing my name below and selecting "Submit", I hereby release both of the above parties from liability which may result from furnishing this information.

First Name

Last Name