Release/Request For Information

Hereby Authorizes

Of Rock Landing Psychological Group

The Purpose of this disclosure shall be for:

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.

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