• Chantel Cohen, LCSW

    550 Pharr Road NE, suite 205 Atlanta, GA 30305 

    Phone: 470-296-3090
    Email: chantel@chantelcohen.com

    Consent to Release Confidential Information
 [If you wish to grant permission for therapist to share any info with a 3rd party]

  • do hearby, consent and authorize: Chantel Cohen, LCSW to receive from, release to, or exchange with:
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  • I understand that information disclosed above is protected by Federal Regulation 42CFR, Part 2, and cannot be released without my written consent unless otherwise required by law. I understand that I need not consent to the disclosure of information in order to obtain treatment services. I choose to do so willingly and voluntarily for the purposes specified above. The duration of this authorization is no longer than one year unless I specify a date, event or condition upon which it will expire sooner. I understand that I may revoke this consent at any time by notifying Chantel Cohen in writing, except to the extent that action has been taken in good faith on my consent.
  • If you do not wish to use the online form, please download and complete application in full, print it and be sure to sign and date it.