Re-create Treatment Team Exchange Form

I need to have someone re-create the treatment team exchange form in the format of the file attached. I've created it and put a password on it that I cannot remember (ugh!!). There are a few changes I'd like to have: 1. The header should be changed to read: Treatment Team Consent to Exchange Information Marriage & Family Therapy Services, Inc. DBA: Bright Road Recovery 428 Harrison Avenue, Suite 101 Claremont, CA 91711 909-994-1436 [login to view URL] line should read: I, the above named client, authorize Bright Road Recovery (staff and directors) and the following named providers/individuals to exchange information regarding my treatment. 3. Create the following fields for a total of eight providers: a) Provider/Individual Name b) Role (drop down list to include: Psychotherapist, Dietitian, Psychiatrist, Physician, Other Professional Support, c) email d) phone e) fax 4. Change "Additional Providers" to "Family/Friend/Non-professional Support"; make this a text box that is able to grow to type in names and contact information as necessary. 5. All remaining information as on form attached. 6. I'd like the whole of this form to fit on one page. 7. Additional information: Need fast turn around No typos Form not editable by end users I need a copy of the form in a file that I can edit and change as necessary Thanks