• Mitchell Rosen, LMFT

    43537 Ridge Park Drive, Suite 100

    Temecula, CA 92590

    (951) 541-3158 

  • Authorization to Release Confidential Information    


  • to release confidential information obtained during the course of my treatment to Mitchell Rosen, LMFT [person to which information is to be released]

  • I understand that I have a right to receive a copy of this authorization. I also understand that any cancellation or modification of this authorization must be in writing. 

  • Copyright California Association of Marriage and Family Therapists. Rev. 02/04    

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