• Debra Caplowe, LCSW

    REQUEST TO RELEASE/EXCHANGE RECORDS AND INFORMATION
  • 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.

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  • I understand that this authorization may be revoked at any time to the extent that action based on this consent has been taken.

  • Clear
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  • DEBRA CAPLOWE, LCSW | Licensed Clinical Social Worker

    131 W. Great Falls Street, Suite 101, Falls Church VA 22046 | 703-795-4226

  • Should be Empty: