Release/Request For Information

Adult Services

CHILD/TEEN SERVICES

Teletherapy

Client Name

Date Of Birth

Social Security Number

Name Of Individual

Hereby Authorizes

Name Of Therapist

Of Rock Landing Psychological Group

Obtain information from

Release information to

Relationship to Client

Name

Address

Telephone - FAX

The Purpose of this disclosure shall be for:

Further medical/psychiatric care

Coordination of care

Other

Specific information requested:

This authorization shall remain in effect for 12 months from today's date and may be revoked at any time upon written notification of the patient and/or guardian.

Signature

Clear

Date

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Where We Are

Rock Landing Psychological Group, PLC
The James Building
11825 Rock Landing Drive
Newport News, VA 23606
Phone: (757) 873-1736
Fax: (757) 873-1028