I authorize Dr. Barbara Morris Jensen to release and/or exchange information about me, or my minor child, Patient First Name* Patient Last Name* with the person/agency named below. This information may include current and/or prior psychological, alcohol/drug treatment or medical services, diagnostic impressions, education and academic testing or performance, assessment findings, and recommendations.
This consent expires on Date or one year from the date below. I understand I may change or revoke this consent by submitting a request in writing. I understand I have a right to request a copy of this authorization. A photocopy of this signed form is as valid as the original. Patient First Name*