Authorization to Release Confidential Information

- Request for Records -

I, _____________________________________   authorize Peter M. Bradlee, Ph.D. to

send_____ receive ______records on_______________________________________

to:___________________________________________________________________                                                                 Address/phone_________________________________________________________

            ( )   Academic Testing Results                    ( )   Psychological Testing Results

            ( )   Behavior Programs                               ( )   Case Notes

            ( )   Medical Reports                                    ( )   Summary Reports

            ( )   Intelligence Testing Results                  ( )   Entire Record

            ( )   Psychological Reports                          ( )   Other (specify)____________________

The above information will be used for the following purposes:

          ( )   Planning/Continuing Appropriate Treatment

          ( )   Determining Eligibility for Benefits or Program

          ( )   Case Review

          ( )   Other (specify)_____________________________________________

I understand that I may revoke this consent at any time by providing written notice, except that revocation shall not affect any action already taken in reliance on the existence of this authorization. If not revoked earlier, after one year this consent automatically expires.

I have been informed what information will be given, its purpose, and who will receive the information.

Signature of Client _______________________________________Date________________

Signature of Parent/Guardian ___________________________________ Date___________

Signature of Person Informing Client of Rights __________________________Date_______