By checking the box above, I voluntarily authorize Henriquez Counseling and Wellness, and service providers acting on its behalf, to share my name, email address, phone number, country, IP address, browser and device information, ad click identifiers, the web address of the page where I submitted this form, and the fact that I am inquiring about therapy services with Meta Platforms, Inc. (Facebook/Instagram) for advertising measurement and campaign optimization purposes. No diagnosis, symptoms, survey answers, or details about my care are shared. Checking this box is optional, and my ability to receive services is not conditioned on it. This authorization expires 12 months from the date I submit this form, or sooner if I revoke it. I may revoke this authorization at any time by sending a written request to [email protected]. Revocation will not affect information already shared before my request is received. Information shared with Meta may no longer be protected by HIPAA and may be redisclosed by Meta according to its own privacy policy. A copy of this authorization will be emailed to me.