RELEASE OF INFORMATION
CENTER FOR PSYCHOLOGICAL & EDUCATIONAL ASSESSMENT
Name of client of record:
*
First Name
Last Name
Client birthdate:
-
Month
-
Day
Year
Date
I request and authorize (psychologist name):
*
Please Select
Dr. Dana Davis Weinstein
Dr. Melissa Lang
Serena Meyer, M.A.
To obtain from or exchange with:
*
Name of person or agency with whom we are sharing information
The following information:
Educational records, medical records, test results, observations
For the purposes of:
Evaluation, therapy, record update
Phone number of person receiving information:
Please enter a valid phone number of the person to whom you are releasing information
Format: (000) 000-0000.
Email of person receiving client information:
example@example.com
Mailing address of person receiving client information:
Signature (use mouse if no touch screen)
*
Printed name:
First Name
Last Name
Date
/
Month
/
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Submit
Should be Empty: