Mitchell Rosen, LMFT
43537 Ridge Park Drive, Suite 100
Temecula, CA 92590
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