Exchange Info - Joy A. Dryer Ph.D

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.
Mediator Coach 1 Name
Mediator Coach 1 Phone
Mediator Coach 1 Fax
Mediator Coach 2 Name
Mediator Coach 2 Phone
Mediator Coach 2 Fax
Attorney 1 Name
Attorney 1 Phone
Attorney 1 Fax
Attorney 2 Name
Attorney 2 Phone
Attorney 2 Fax
Financial Specialis Name
Financial Specialis Phone
Financial Specialis Fax
Other Name
Other Phone
Other Fax
Client 1 Name
First Last
Client 1 Signature
Client 2 Name
First Last
Client 2 Signature
Date
MM slash DD slash YYYY

JOY A. DRYER Ph.D