Consent for Release of Information

Amanda Nelson Mandel, Psy.D.

330 West 58th Street ￨ Suite 203 ￨ New York, NY 10019917.690.6090 dr.amanda.mandel@gmail.com
Consent for Release of Information
I hereby authorize Amanda Nelson Mandel, Psy.D., to receive and/or release confidential information from the records of:
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Information to be released includes:*
This information is authorized for Release from/to:
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
I am aware that information in my records is personal and confidential and can only be released with my consent. By my signature, I agree that I thoroughly understand the content of this form, and I consent to release the specified information. I understand that this release of information remains valid for a period of one year from the date of my consent. However, I may withdraw consent at any time.
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Date*

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Date
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Date*

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Date
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Amanda Nelson Mandel, Psy.D.