RELEASE OF INFORMATION

This is a release so that your mediator or mediators may consult with your therapist, physician, children’s therapists, schools, accountants, extended family members or whomever else you decide.

I authorize those persons or agencies listed below to share with
Susan J. Kraus, M.S.W. ____Frank Barthell, M.S. ____Verdell Taylor, M.S._____
either verbally, by e-mail or in writing, documentation and information that will enable them to more accurately and efficiently assess relevant issues and reach resolution in the custody and / or property mediation process in which I am engaged. In so doing, I waive my right to confidentiality.

Such persons or agencies include :

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Signature ________________________________________________________

Name (print) ______________________________________________________

Date _____________________________________________________________

Address __________________________________________________________

Contact Phone # __________________________Cell _____________________