Consent Form

I,

authorize Dianna Chillo, LCSW-R, to obtain from

to disclose to

Name of person/facility

Address and Phone number

The following information (check all that apply)

The Purpose of this disclosure is:

To Facilitate treatment

Coordination of care

Coordinate treatment efforts with family/significant others

Other

Please type name of Patient (or parent or guardian). By typing your first and last name below you are agreeing that this is your electronic signature.

Date

Dianna Chillo, LCSW-R

Psychotherapist

“Mental Strength is not the ability to stay out of the darkness; it’s the ability to sit present in the darkness knowing that the light will shine again.”

Consent Form