RELEASE OF INFORMATION
CENTER FOR PSYCHOLOGICAL & EDUCATIONAL ASSESSMENT
Name of client of record:
*
First Name
Last Name
Client birthdate:
-
Month
-
Day
Year
Date
I request and authorize (psychologist name):
*
Please Select
Dr. Dana Davis Weinstein
Dr. Melissa Lang
Dr. Adria Garrett
Dr. Christine Rose
Dr. Christine Hook
Dr. Lisa Palmer
Dr. Christy Jaffe
Dr. Jamie Miller
Dr. Michelle Washington
Dr. Quynh Doan Wellons
not sure
To obtain from or exchange with:
*
Name of person or agency with whom we are sharing information
The following information:
Educational records, medical records, test results, observations
For the purposes of:
Evaluation, therapy, record update
Phone number of person receiving information:
Please enter a valid phone number of the person to whom you are releasing information
Email of person receiving client information:
example@example.com
Mailing address of person receiving client information:
Signature (use mouse if no touch screen)
*
Clear
Printed name:
First Name
Last Name
Date
/
Month
/
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Submit
Should be Empty: