Mitchell Rosen, LMFT
43537 Ridge Park Drive, Suite 100
Temecula, CA 92590
Authorization to Exchange Confidential Information
hereby authorize Mitchen Rosen, LMFT to exchange confidential information regarding my treatment with:
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