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Release of Information Form

Bravery is not the absence of fear. Bravery is feeling the fear, the doubt,
the insecurity, and deciding something else is more important
– Mark Manson

1 Step 1
Trident Healing Release of Information Form
For the Disclosure Mental and Personal Health Information
My Date of Birth is
Authorize Scott Blundo, dba Trident Healing, to obtain from
The following information:
Select All Information - or all that apply for you
I understand that this information may be used or disclosed in connection with mental health treatment, payment, or healthcare operations. I further understand that I will be furnished a copy of this release if requested. This expiration may be revoked at any time. This agreement shall expire automatically one (1) year from the date this release is signed.
Client Name
Client Name
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