Release of Information Medical / psychological practitioner's name and contact information: * Patient name (or parent/guardian if patient is under 18): * First Name Last Name Patient phone (###) ### #### Patient email * Message By submitting this form with my signature below, I give my consent for John Mongiovi, BCH, CI, to release my personal information to the following persons(s) only, and to discuss with them my treatment and any information of which he may become aware in the course of our professional interaction: * I consent to this statement. Thank you for your interest. I will contact you when the next course is being planned.