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Dr. Andrew Graham

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Client Forms: Files

Release of Information

Use this form if you would like to give me permission to discuss your case with someone else.

First name

Email

Last name

Date of Birth

I authorize Dr. Andrew Graham to: *

Release Information

Obtain Information

Name/Organization and Contact Information:

I authorize information to be released by the following methods: *

Phone

Email

My signature below indicates that I understand that I do not have to sign this authorization and my refusal to sign will not affect my ability to obtain counseling and that I may revoke this authorization at any time by submitting a written request to Dr. Andrew Graham. I certify that this form has been fully explained to me and I understand its contents.

Type Name as Signature Here

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