Home
About
Services
Getting Started
Resources
Contact
- Employment Opportunities
Blog

317-207-9333 | info@restorationcounselingindy.com

Kelly Shores | Restoration Counseling

Don't Wait to Get the Help You Need Start Here

Authorization for Release of Information copy

September 1, 2016 by Kelly Shores Leave a Comment

Authorization for Release of Information copy

314 Elm Street
Fortville, IN 46040

317-207-9333
info@restorationcounselingindy.com

Send a Message

Name *

E-mail *

Phone

Comment or Message

Terms of Use *

Yes, I want to submit this form

By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Brighter Vision harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.

Name

A Bright Site by Brighter Vision