I understand my case history as outlined below (the "Case Study") and made on behalf of Blue Umbrella Psychiatry (BUP) may be used in connection with promotion/community education.  I authorize BUP to cite my gender and age only, concealing my name and any additional demographic information, but sharing the Case Study as defined on this form. I authorize BUP to copy, publish or distribute the Case Study for purposes of educating and informing others.

These statements may be used in printed publications, on websites or in any other distribution media. I agree that I will make no monetary or other claim against BUP for the use of the statement. In addition, I waive any right to inspect or approve the finished product, including written copy, in which my testimonial appears. Case History facts to include:

1. Patient Gender, Patient Age - no mention of name or identifying city 
2. Patient Story - At intake; Clinical, Emotional, Lifestyle
3. Treatment consisted of: Medication/TMS/Sprovato/Therapy, etc.
4. Upon completion of treatment: Clinical, Emotional, Lifestyle
5. Any key success story -  ie new job, new or improved relationships, life decision, etc. 
6. Scores of clinical assessments over time without identifying information.