I (We) authorize Gary J. Coenen, M.S. of LifeStyle by Choice, 313 Price Place, Suite 206, Madison, WI.

to release specific information to include: _______________________________________________________

from the clinical record of _______________________________________________________ ____________
                                               (Name of client/recipient of Clinical Hypnosis / Counseling Services)   (Date of birth)

for the purpose of __________________________________________________________________________                                                                                                                                  .
                                            (facilitating counseling/consultation, and/or conducting an evaluation, etc.)

I understand that I have the right to revoke this authorization, in writing, at any time by sending notice to
Gary J. Coenen of LifeStyle by Choice. I understand that a revocation is not valid to the extent that
Gary J. Coenen of LifeStyle by Choice has acted in reliance on such authorization.
This authorization is valid until ________________________________________________________________.                                                                             .
It has been explained to me that If I refuse to consent to this release of information, the following are the
consequences, if any:
A copy of this release shall have the same force and effect as the original.

(Client Signature(s)) ______________________ Date ________              ______________________ Date ________             

____________________________________ _________      _______________________________ ________
(Client Signature 12 yrs. or older)                        (Date)                     (Parent/Guardian Signature)               (Date)  

NOTICE TO RECEIVING FACILITY/THERAPIST:  You may not redisclose any of this information unless the
       person who consented to this disclosure specifically consents to such redisclosure.  I understand that there
       is a potential for redisclosure of this information by the recipient and, if that occurs, the information may not
be protected by Federal law.