Request/Authorization to Release and Exchange Information with

Dr. Linda Leiphart

Confidential Records and Information

I hereby authorize (person or facility):

Address

For the purpose of:

Further mental health evaluation, treatment, or care

Treatment planning

Other

These psychological/psychiatric records concern the time

Intake and discharge summaries

Medical history and evaluation(s)

Behavioral/Mental health evaluations

Developmental and/or social history

Educational records

Progress notes, and treatment or closing summary

Other

Please forward the records to Dr. Linda Leiphart, PO Box 35174, Tucson, AZ .

This request is entirely voluntary on my part. This consent will expire automatically after one year from the date on which it is signed, or upon fulfillment of the purposes stated above.

Signature of client

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Printed name

Date