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