PERMISSION TO RELEASE INFORMATION

Patient: DOB: Date:

Name of Parent:

I (We) hereby authorize and request (please fill in name and address of person you want me to communicate with):

Name:

Address:

Phone: Fax:

L. Eileen Keller, Ph.D.
5435 College Ave, # 201
Oakland, California 94618
(510) 654-2420
(510) 893-0247 fax

The information requested is as follows:

Two-way consultation regarding this individual's current and previous condition.

It is agreed that this information will not be released to any other source without the express, written permission of the patient or guardian. In consideration of this consent, I hereby release the above parties from any and all liability arising from the release of this information. This release of information may be revoked at any time in writing.

Patient/Parent Signature: Date: