Authorization to Release Personal Information

Your Name

hereby authorize Biana Bochkur, PsyD to release records pertinent to services provided to me to:

Name of Person or Organization to which Disclosure is made

Address of Person or Organization to which disclosure is made

The disclosure is required for the following purpose(s)

And such disclosure shall be limited to the following types of information

This consent form is subject to revocation. My consent may be revoked at any time by written revocation. If no express revocation is made, this consent shall terminate in six months from the date of this authorization or upon termination of the services provided to me by Biana Bochkur, PsyD, whichever period of time is shorter.

Expiration Date

Month

Day

Year

Signature

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Date

Month

Day

Year

Signature of Parent or Guardian (if applicable)

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