The persons or agency m y Release information to Dr. Rhonda Greenberg and Psychotherapy and Trauma Therapy LLC about my and/or my child’s personal, health, legal and/or education information: (The information to be released is described in Section III below.) Initials: Mr. on left and Mrs. on right Name: Address: Agency Contact and Title: PROVIDING AND RECEIVING PERSON OR AGENCY THE INFORMATION: 1i. The persons or agency may Release information to Dr. Rhonda Greenberg and Psychotherapy and Trauma Therapy LLC my and/or my child’s personal, health, legal and/or education information: (The information to be released is described in Section III below.) Initials: Mr. on left and Mrs. on right Name: Address: Agency Contact and PROVIDING AND RECEIVING I j. PERSON OR AGENCY THE INFORMATION: : The persons or agency may Release information to Dr. Rhonda Greenberg and Psychotherapy and Trauma Therapy LLC about my and/or my child’s personal, health, legal and/or education information: (The information to be released is described in Section III below.) Initials: Mr. on left and Mrs. on right Name: Address: Agency Contact and Title: PROVIDING AND RECEIVING PERSON OR AGENCY THE INFORMATION: 1k. The persons or agency may Release information to Dr. Rhonda Greenberg and Psychotherapy and Trauma Therapy LLC about my and/or my child’s personal, health, legal and/or education information: (The information to be released is described in Section III below.) Initials: Mr. on left and Mrs. on right Name Address: Agency Contact and Title: PROVIDING AND RECEIVING PERSON OR AGENCY THE INFORMATION: 1l.
The persons or agency m y Release information to Dr. Rhonda Greenberg and Psychotherapy and Trauma Therapy LLC about my and/or my child’s personal, health, legal and/or education information: (The information to be released is described in Section III below.) Initials: Mr. on left and Mrs. on right Name: Address: Agency Contact and Title: 1i. PERSON OR AGENCY PROVIDING AND RECEIVING THE INFORMATION: The persons or agency may Release information to Dr. Rhonda Greenberg and Psychotherapy and Trauma Therapy LLC my and/or my child’s personal, health, legal and/or education information: (The information to be released is described in Section III below.) Initials: Mr. on left and Mrs. on right Name: Address: Agency Contact and I j. PERSON OR AGENCY PROVIDING AND RECEIVING THE INFORMATION: : The persons or agency may Release information to Dr. Rhonda Greenberg and Psychotherapy and Trauma Therapy LLC about my and/or my child’s personal, health, legal and/or education information: (The information to be released is described in Section III below.) Initials: Mr. on left and Mrs. on right Name: Address: Agency Contact and Title: 1k. PERSON OR AGENCY PROVIDING AND RECEIVING THE INFORMATION: The persons or agency may Release information to Dr. Rhonda Greenberg and Psychotherapy and Trauma Therapy LLC about my and/or my child’s personal, health, legal and/or education information: (The information to be released is described in Section III below.) Initials: Mr. on left and Mrs. on right Name Address: Agency Contact and Title: 1l. PERSON OR AGENCY PROVIDING AND RECEIVING THE INFORMATION:
Consent-form-forensic-NF.docx