Psychological-Medical Information Release

PLEASE FILL OUT ONLY IF REQUESTED BY YOUR THERAPIST

psychologist, physician, or agency

Date

City/State

Email address

Phone

Specific uses and limitations on information to be disclosed:

Specific date after which provide is no longer authorized to disclose information:

I hereby authorize you to release psychological, medical, or educational information contained in the record of:

Name(s) Date of Birth

This information is required to assist the above named agency or person in determining the type of services needed.

Signature

Address

City/State

Phone

Date Signed

Your information will be encrypted.