Release Info Form

Release Info

  • PERMISSION to RELEASE INFORMATION 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

    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.

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

  • II. In Another circumstance:

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