Form52 - Signature of client Printed name Date Signature of...

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[ FORM 52 —Use the top of this page for your letterhead.] Request/Authorization for Release of Evaluation Information Client: Address: Phone: Birthdate: Social Security #: Regarding the administration of psychological tests, I give my permission to (select only one): q the professional named in the letterhead at the top of this form, or q of to release the results of the tests taken by me/the patient, in order to: q Assist with treatment planning q Document a need for services q Support an application for q Other: and to send these records to (select only one): q the professional named in the letterhead, or to q of I hereby release the person or organization sending these records and results from any liability associated with adminis- tering, scoring, interpreting, evaluating, reporting, or transmitting the results of these tests. I understand that the records, information, or results will not be given to me by the evaluator.
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Unformatted text preview: Signature of client Printed name Date Signature of parent/ Printed name Relationship Date guardian/representative I witnessed that the person understood the nature of this request/authorization and freely gave his or her consent, but was physically unable to provide a signature. Signature of witness Printed name Date q Copy for client or parent/guardian q Copy for source of records q Copy for recipient of records FORM 52. Request/authorization for release of evaluation information. Adapted from a form devised by Ruth H. Sosis, PhD, of Cincinnati, OH, and used by permission of Dr. Sosis.From The Paper Office . Permission to photocopy this form is granted to purchasers of this book for personal use only (see copyright page for details)....
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