PERMISSION to RELEASE INFORMATION Form
JOY A. DRYER, Ph.D.
Licensed Psychologist/ Psychoanalyst
PACT Certified Clinician
NYState License #7740
92 Remsen Street Ste. 1A, Blyn Heights NY 11201
31 Collegeview Avenue. Poughkeepsie, NY 12603
I. With Colleagues
I, __________________________ , give permission for Dr. Dryer to consult with other colleagues involved in working therapeutically with me. This includes exchanging oral or written information about me that is pertinent to my care. I also understand that this Permission is voluntary and I can revoke it in writing at any time.