waiver of confidentiality URLThis field is for validation purposes and should be left unchanged.Client(Required) Full Name Birth date & place Consent: I hereby release Ms. Susanne Stauch, Heilpraktikerin für Psychotherapie, from her duty of confidentiality with respect to(Required)Name of the person or institution you'd like to give consent to:This is(Required)my doctormy therapistmy partnermy familya facility/practice/teamother...other: please specify (profession, role)phone/ emailplease provide if availableConditions(Required)I have been informed that I may revoke this release from confidentiality at any time in writing (fax, email, mail). I confirm to have read and understood the conditions.Unterschrift(Required)