YouTube Release of Information – MCL Counseling & Hypnosis

Name *

First

Last

Date of Birth

Agency / Relationship

I give permission to MCL Counseling and Hypnosis, LLC and Michael Landgren, LICSW to OBTAIN and RELEASE information on social media including company website and YouTube. I understand that this information will be available to the public and that I will not be able to share or control who views this. Disclosure can include:

Name mentioned
Photo and video images
Personal information that I mention on YouTube video and or website
Mental Health, Drug and alcohol information including diagnoses, treatment

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email *

I authorize the above information to be shared. I understand that in doing so, MCL Counseling and Hypnosis, LLC and Michael Landgren, LICSW is not liable for how this information is transmitted and can not be held liable for any breaches in confidentiality due to electronic transmission.

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