Consent of Client to Release of Information

Client Name

I hereby give my permission for any representative of Gateway Counseling

Centers, Inc. to release, or receive, information on the above-referenced
client to/from the following:

Purpose or need of disclosure:

Extent and nature of information to be exchanged:

I understand that this authorization is subject to revocation at any time, or

one year from the date of the signing, except to the extent that action has
been taken in reliance thereon.

Client or Client Representative Witness

Date Date

Revocation:

Client or Client Representative Witness

Date Date