Authorization for Release of Info

11 West 33rd St., Erie, PA 16508

Please print page and mail the filled out form to the above address.

Date____________________

I __________________________ permit __________________________ to release my:
(name of client)
(name of psychologist)

(a) progress notes;

(b) treatment sumniaiy;

(c) psychological evaluation;

(d) other (specify) _____________________

to _____________________at____________________________________________
(provider/agency)
(address)

for the purpose of:
(a) developing a treatment plan;

(b) other (specify)

I may revoke this release at any time except to the extent that the person who is to make the disclosure has already acted upon it. Except as noted above, this release will expire_____days from now or under the following circumstances: ____________________________________

Client or Guardian:________________________________

Witness:_______________________________

Date:___________________ Date:__________________