AUTHORIZATION FOR RELEASE OF INFORMATION

From:

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  • THE ABOVE NAMED INDIVIDUAL IS AUTHORIZED TO DISCLOSE THE FOLLOWING INFORMATION REGARDING:

  • Client Name(*)
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  • To:

    David W. McMillan, Ph.D
    115 28th Avenue North
    Nashville, TN 37203
    615-327-2183

    Information to be released (Check appropriate items):
     Social History Diagnoses/Impressions Psychological Testing Medical History Treatment Notes

  • Other
  • The purpose of this disclosure is (Check appropriate items)
     To assist with this individual’s evaluation Other

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  • I acknowledge that the information being released was fully explained to me and this consent is given freely.

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