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Authorization for Release/Exchange of Information


This form provides your therapist with written permission to communicate with other individual providers regarding your treatment (e.g. previous treating therapist, current health care providers, parents or school).

Thanks for submitting!

I authorize my therapist, Beth Holt Wright, to release/exchange the following information to:

Indicate which of these items can be released with a "yes" and those you do not want released with a "no."

In providing your electronic signature, you agree that an emailed or electronic signature shall be the equivalent of an original signature on this agreement in accordance with the Uniform Electronic Transactions Act, Virginia Code Section 59.1-479, et seq.

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