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:__________________