Professional and Caring Psychological
Services
Saint Louis, Missouri
Client:
___________________________ DOB:___/___/200__
| I
(We) hereby authorize and request (name of the person you want me to communicate with such as, "East High School Personnel"): |
||
| Name:
|
||
| Address: | ||
| City:_________________________ State:______Zip: | ||
| Phone: ( ____ )_____-_______ Fax: ( ____ )_____-_______ |
to release confidential professional information, including personal, psychological, psychiatric, and medical records and opinions, resulting from my contacts with them to:
Thomas
M. Krapu, Ph.D.
11222 Tesson Ferry Road Ste 200
Saint Louis, Missouri 63123
(314) 842-2258 (voice) (314-842-3277 fax)
email: 
http://www.krapu4.com/psy/
The information requested is as follows:
Two-way consultation regarding this individual's current condition.
It is agreed that this information will not be released to any other source without the expressed written permission of the patient or their guardian(s). In consideration of this consent, I hereby release the above parties from any and all liability arising therefrom. This release of information may be revoked at any time in writing.
| Signed________________________________ |
Date___/___/____ | |
| Signed________________________________ |
Date___/___/____ | |
| Signed________________________________ |
Date___/___/____ | |
Return to Dr. Krapu's Home Page
(11/5/02)
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(314)
842-2258
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fax on request
|
