INFINITE GROWTH RELEASE OF INFORMATION CONFIDENTIAL

The communication between you and Infinite Growth Limited Liability Company is confidential. This means that we will not disclose or discuss information about you without anyone without your express written consent. There are certain occasions in which confidentiality may be broken as governed either by legislation, government regulations and/or court orders. These are but not limited to:

An emergency in which your life is in danger and which you are unable to provide information on your own.
If in our judgement you are a danger to yourself or others. In this case, we may be required to inform another healthcare provider, hospitals, specific individuals and/or a government/regulatory body.
When we are ordered to release information on your behalf by an appropriate legal authority.
When, in the case of an individual who has a guardian, such as a minor child, the guardian gives explicit written permission to do so.
When reporting is required by state-law, such as in the case of alleged child or adult neglect.

I have read the above disclosures and/or this disclosure has been explained to me. I understand and accept these arrangements of confidentiality.

Client First Name

Client Last Name

Parent/Guardian Full Name

Client Signature or Parent/Guardian Signature

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Date

INFINITE GROWTH RELEASE OF INFORMATION CONFIDENTIAL

An emergency in which your life is in danger and which you are unable to provide information on your own.
If in our judgement you are a danger to yourself or others. In this case, we may be required to inform another healthcare provider, hospitals, specific individuals and/or a government/regulatory body.
When we are ordered to release information on your behalf by an appropriate legal authority.
When, in the case of an individual who has a guardian, such as a minor child, the guardian gives explicit written permission to do so.
When reporting is required by state-law, such as in the case of alleged child or adult neglect.

I have read the above disclosures and/or this disclosure has been explained to me. I understand and accept these arrangements of confidentiality.

Client First Name

Client Last Name

Parent/Guardian Full Name

Client Signature or Parent/Guardian Signature

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Date