Consent to Release Confidential Information

Avvy Mar, Ph.D.
3434 SW Kelly Avenue
Portland, OR 97239
503 313-7743
Licensed Psychologist (OR #2890 / CA #17806)

Consent to Release Confidential Information
_____________________________________________________________

Name*

First NameLast Name

I hereby authorize Dr. Avvy Mar to speak with name* to share any relevant information concerning me in regard to my treatment. Dr. Mar has my permission to receive information from name* concerning me and any information
relevant to my welfare.

I understand that this authorization shall become effective immediately and shall remain in effect as long as it is necessary for Dr. Mar.

I acknowledge that executing the authorization is voluntary and completely waive and release the limits of confidentiality I may have concerning these records and information, and agree to hold Dr. Mar harmless and indemnify her from any and all claims made against her in connection with the release of these records and information as authorized. I affirm that everything in this form that was not clear to me has been explained to my satisfaction.

A photocopy of this release is to be considered as valid as the original.

Printed name of client*

Signature of client*

Date*

Date