Authorization to Release Information

The confidentiality of this record is required under the California Civil Code 56-56.37, as well as Title 42 of the United States Code. This material shall not be transmitted to anyone without written consent or authorization as provided in these statutes.

I, ______________________________, hereby authorize Daniel Sonkin, Ph.D. (Marriage and Family Therapist License number: MFC16644) to disclose information and records obtained in the course of my diagnosis and/or treatment to: _____________________________.

Such disclosure will be limited to the following specific types of information:

__________ Dates of admission and discharge

__________ Diagnosis

__________ Pertinent medical and/or psychiatric information relevant to diagnosis and treatment

__________ School records/information/testing

__________ Other information (please specify) _______________________

__________________________________________________

This disclosure of information and records authorized herein is required (by the receiving party) for the following purpose: _____________________________________________

The specific uses and limitations on the types of medical information to be disclosed are as follows:
_____________________________________________

My birthdate is: ________________

Date of last contact: ________________

--------------------------------------------------------------------------------------------------------------------------------------
This authorization will expire 60 days from date of signature. I understand that I have a right to receive a copy of this authorization. I also understand that this authorization may be revoked by me, in writing, at any time, except to the extent that action has already been taken.

________________________
Print Name
________________________
Signature
__________
Date
______________________
Witness' name
______________________
Signature
__________
Date