Release of information

This is a “permission slip” that gives permission for me to be in contact with someone else and share/receive information regarding your care. If you have other providers you’d like me to collaborate with (doctors, dietitians, couple’s counselors, etc), please complete one form for each provider.

If you have any questions or need to reschedule your appointment, you’re welcome to send an email to khagar@mindfullybalancedtherapy.com or call/text (847) 447-2919.