to release/exchange information from the records of:
This authorization is signed with the understanding that the information will not be passed on to anyone else, or be used for any other purpose other than specified.
I understand that this authorization may be revoked at any time to the extent that action based on this consent has been taken.
DEBRA CAPLOWE, LCSW | Licensed Clinical Social Worker
131 W. Great Falls Street, Suite 101, Falls Church VA 22046 | 703-795-4226