Regarding: _____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Date of Birth: __________________________________________________________________

Soc. Sec. #: ___________________________________________________________________


I consent to the sharing of information regarding the above-named person(s), between Thomas G. Parker, Ph.D. and the patry listed below. The information will be used in evaluation or treatment of the person named, and will be subject to all applicable laws and codes regarding confidential medical records.





Name of party to whom this release applies:


Name: _____________________________________________________________________________

_____________________________________________________________________________

Address / telephone: _____________________________________________________________________________

____________________________________________________________________________




Signed:


_______________________________________________________________________
Parent___Legal Guardian___Legal Representative___


Relationship to the client:

Date: __________________________________________________________________________
..