Janneta Bohlander & Associates, LLC

Janneta Bohlander, LMFT

83 East Avenue, Suite 208

203-521-0805

Janneta Bohlander, LMFT

CT license number 000955

Tax ID 20-3204106

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I understand that my health information is protected by law. I authorize the release of my confidential health information as indicated above. I understand that my consent is voluntary and I can revoke this permission at any time, except to the extent that it has already been shared based on this authorization. Should I choose to revoke this authorization I will state this in writing.

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