Exchange Info

Exchange Info Consent

  • Mediation / Collaborative Divorce
    Exchange of Information Consent Form


    JOY A. DRYER, Ph.D.

    Licensed Psychologist/ Psychoanalyst
    PACT Certified Clinician
    NYState License #7740
    jdryerphd@gmail.com

    92 Remsen Street Ste. 1A, Blyn Heights NY 11201
    31 Collegeview Avenue. Poughkeepsie, NY 12603
    www.joydryerphd.com
    Cell: 917-816-8882


  • We request and authorize the following professionals to exchange information with one another to better facilitate the Mediation and/ or Collaborative Divorce process. Thus, I/ we agree to waive my/ our confidentiality privileges among the professionals involved in my/ our case:

    If not previously revoked in writing, this consent will terminate upon signing the Separation/ Divorce Agreement.

  • Reset signature Signature locked. Reset to sign again
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  • MM slash DD slash YYYY