Release of Information "*" indicates required fields I give permission for my treating clinician at Jonah Green and Associates, LLC to exchange informationClient First & Last Name*Email* With the following person or entities:NameEmail PhoneAddressThe PHI to be disclosed includes the following:* Assessment Information Diagnosis Treatment Planning Notes Progress & Treatment Notes Medication Recommendations Results of Psychological Testing Psychiatric Evaluation Reasons for Termination Other Name of client or client’s guardian*Signature of client or client’s guardian*Date* MM slash DD slash YYYY Name of client or client’s guardianSignature of client or client’s guardianDate MM slash DD slash YYYY Therapist*Please SelectJonah Green, LCSW-CAron Carlson, LCSW-CHeidi Cohen, LCSW-C, CGABSDani Delgado, LCPCKatherine Doyle, LMSWChris Erb, LCMFTJennifer Firestone, LCSW-CShannon Golub, LMSWShannon Harris, LMSW, MBA, RYT-200Lucy Kaminska-Silver, LCSW-CYasmin Meyers, LCSW-CJamie Rosen, LMSWLori Rothfeld, JD, LMSWFarah Shirazi, LCSW-CCAPTCHAPhoneThis field is for validation purposes and should be left unchanged. Updated: 2/27/2025