I
First Name* @if(isset($formObj['customs']['client_fname'])) {{$formObj['customs']['client_fname']}} @else @endif	Last Name* @if(isset($formObj['customs']['client_lname'])) {{$formObj['customs']['client_lname']}} @else @endif
@if(isset($formMetaObj['meta']['CONTENT'])) {!! $formMetaObj['meta']['CONTENT'] !!} @endif
Coach* @if(isset($formObj['customs']['counselor'])) {{$formObj['customs']['counselor']['first_name']}} {{$formObj['customs']['counselor']['last_name']}} @if(isset($formObj['customs']['counselor']['post'])) ({{$formObj['customs']['counselor']['post']}}) @endif @else @endif

Phone* @if(isset($formObj['contact_info']['phone'])) {{phoneFormat($formObj['contact_info']['phone'])}} @else @endif	Street Address* @if(isset($formObj['contact_info']['street_address'])) {{$formObj['contact_info']['street_address']}} @else @endif	Address Line 2 @if(isset($formObj['contact_info']['address_line_2'])) {{$formObj['contact_info']['address_line_2']}} @else @endif	City* @if(isset($formObj['contact_info']['city'])) {{$formObj['contact_info']['city']}} @else @endif
State* @if(isset($formObj['contact_info']['state'])) {{$formObj['contact_info']['state']}} @else @endif	Zip Code* @if(isset($formObj['contact_info']['zip'])) {{zipFormat($formObj['contact_info']['zip'])}} @else @endif	Country* @if(isset($formObj['contact_info']['country'])) {{$formObj['contact_info']['country']}} @else @endif

The information will be used for the following purposes:*
@if(isset($formObj['groups']['1']) && in_array('1',$formObj['groups']['1'])) @else @endif follow-up care	@if(isset($formObj['groups']['1']) && in_array('2',$formObj['groups']['1'])) @else @endif billing	@if(isset($formObj['groups']['1']) && in_array('3',$formObj['groups']['1'])) @else @endif placement	@if(isset($formObj['groups']['1']) && in_array('4',$formObj['groups']['1'])) @else @endif scheduling
@if(isset($formObj['groups']['1']) && in_array('5',$formObj['groups']['1'])) @else @endif assessments	@if(isset($formObj['groups']['1']) && in_array('6',$formObj['groups']['1'])) @else @endif other (specify):	@if(isset($formObj['groups']['2'])) {{$formObj['groups']['2']}} @else If other, please specify @endif

The type of information to be released will be the following:*
@if(isset($formObj['groups']['3']) && in_array('1',$formObj['groups']['3'])) @else @endif date(s) of session / scheduling	@if(isset($formObj['groups']['3']) && in_array('2',$formObj['groups']['3'])) @else @endif summary of session/strategies	@if(isset($formObj['groups']['3']) && in_array('3',$formObj['groups']['3'])) @else @endif billing	@if(isset($formObj['groups']['2']) && in_array('4',$formObj['groups']['3'])) @else @endif other (specify):
@if(isset($formObj['groups']['4'])) {{$formObj['groups']['4']}} @else If other, please specify @endif

@if(isset($formMetaObj['meta']['CONTENT_1']))

{!! $formMetaObj['meta']['CONTENT_1'] !!}

@endif @if(isset($formMetaObj['meta']['CONTENT_2']))

{!! $formMetaObj['meta']['CONTENT_2'] !!}

@endif

This authorization is valid until (one year from the date of my signing it.)*

@if(isset($formObj['signature']['sign_date'])) {{date('m/d/Y',strtotime($formObj['signature']['sign_date']))}} @else MM/DD/YYYY @endif

Client’s Signature*

@if(isset($formObj['signature']['client_signature'])) Client’s Signature

@endif

Date*

@if(isset($formObj['signature']['client_sign_date'])) {{date('m/d/Y',strtotime($formObj['signature']['client_sign_date']))}} @else MM/DD/YYYY @endif

Witness’s Signature*

@if(isset($formObj['signature']['witness_signature'])) Witness’s Signature

@endif

Date*

@if(isset($formObj['signature']['witness_sign_date'])) {{date('m/d/Y',strtotime($formObj['signature']['witness_sign_date']))}} @else MM/DD/YYYY @endif

Parent or Guardian’s Signature (if client is under 18 yrs old):

@if(isset($formObj['signature']['parent_signature'])) Parent or Guardian's Signature (if client is under 18 yrs old or adjudicated incompetent):

@endif

Date

@if(isset($formObj['signature']['parent_sign_date'])) {{date('m/d/Y',strtotime($formObj['signature']['parent_sign_date']))}} @else MM/DD/YYYY @endif