Release of Information

Grace Riddell, LICSW, LCSW-C and Associates

griddell4@gmail.com | (202) 669-4379 | www.grace-riddell.com
Signed Permission for Release on Transmittal of Information
I hereby give permission to Grace C. Riddell, LICSW, LCSW-C, to obtain pertinent clinical information.
Patient's Name*

PrefixFirst NameMiddle NameLast NameSuffix
Patient's Date of Birth*

MonthDayYear
Date
Patient's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Therapist/Psychiatrist/Provider's Name*
Therapist/Psychiatrist/Provider's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Therapist/Psychiatrist/Provider's Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Therapist/Psychiatrist/Provider's Email
example@example.com
Signature*

Clear
ClientGuardianPersonal Representative
Date*

MonthDayYear
Date
Please verify that you are human*
Grace C. Riddell, LICSW, LCSW-C and Associates

10027 Frederick Ave., Kensington, MD 20895
Should be Empty:

Grace Riddell, LICSW, LCSW-C and Associates