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Deborah Lee Urban, MEd, NCC, LPC

Release Of Information Form

This form is for the purposes of giving me the permission to have contact with person(s)/organization(s) regarding your care or the care of another of whom you are the guardian. This form will be submitted to my email: DebbieUrbanLPC@aol.com.  If you have any reservations or questions about this form, please contact me by email or call: (314) 304-2942.


I, ( Please provide your contact information:)

Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
E-mail
URL

give permission to Debbie Urban, LPC, to receive/provide verbal/written information from/to:

Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
E-mail
URL

for the purposes of providing continuum of care:

for myself

for the person I am guardian of identified below:

Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
E-mail
URL

I understand that I can revoke this at any time by written request and that this is automatically revoked upon my discharge from Debbie Urban's services. Choose one of the following options:

I agree
I disagree

Please provide any other information that you think should go with this release:

Enter the date of this release:

-- mm/dd/yy

Again, remember that by submitting this form, you are giving me the permission to have contact with the above person(s)/organization(s).  This form will be submitted to my email: DebbieUrbanLPC@aol.com.  If you have any reservations or questions about this form, please contact me by email or call: (314) 304-2942.

Sincere Thanks,

Debbie


Copyright 2004-8 Deborah Lee Urban. All rights reserved.
Revised: March 28, 2010.