I,
_______________________________________________________________________________________
(Print Patient Name)
_______________________________________________________________________________________
(Birthdate and Social Security Number)
give permission to:
______________________________________________________________________
(Name of agency, therapist, doctor, school, etc.)
_________________________________________________________________________________________
(Complete Address)
_________________________________________________________________________________________
(Phone & Fax Number)
to
____ DISCLOSE information to
And/or
____ OBTAIN information from Dr. David W. Sprague, Ph.D.
INFORMATION TO BE DISCLOSED/OBTAINED
___ Psychiatric Information
___ Social Welfare Data
___ Psychological Testing
___ Rehabilitation Records
___ Education Records
___ Legal Information
___ Medical Information
___ Other___________________________________
Limits:_______________________________________________________________________________
I may revoke this consent at any time. If I do not revoke it, this consent will expire one year after I have terminated treatment with Dr. Sprague.
________________________________________________________________________________
(Signature of Patient , Parent or Guardian) (Date)
________________________________________________________________________________
(Signature of Witness) (Date)