(print your name and date of birth)
[Note a date or event upon which this Authorization expires. For example, you may choose to have this authorization expire 1 month from today or 6 months from today; or you may request that this authorization expire upon such event as the termination of consultation with Behavior Basics Incorporated, in which case write down in the space above “termination of therapy with Behavior Basics Incorporated.”]
Signature of professional