Spouse/Significant/ Misc Other Release
  • While I am not a patient of Jodi Valentine Counseling Inc., I have participated or will be participating in the counseling process in order to assist my spouse/significant/misc. other during his/her counseling process.
    I hereby consent for

  • to release to

  • any information about myself obtained by the counselor during these sessions.

  • By entering your name here, you are digitally signing this online form.