James M. Read, Ph.D.
Clinical Psychologist
http://www.jread.com
2304 North Cole Road, Suite B -- Boise, Idaho 83704-7371 -- Telephone (208) 377-0271 -- Facsimile (208) 377-3134
Electronic mail -- jread@jread.com

I, ________________________ for minor: _________________________________________

name of client/patient

name of minor client/patient

authorize only________________________________________________________________

name(s) of service provider(s), agency or institution

to disclose/receive solely to/from James M. Read, Ph.D. for the purpose of:

_____________________________________________________________________________

(treatment, referral, consultation, testing, psychological evaluation etc.)

the following information regarding my diagnosis and treatment (including
information, if any, regarding substance abuse treatment and/or mental health
treatment), the confidentiality of which is protected by federal and/or state law:

_____________________________________________________________________________

(case notes, social and/or psychological history, diagnostic impression, test results and reports, letters, consult reports, medical history and physical report, etc.)

I understand that I have the right to inspect and copy any written information which is disclosed.

I understand that if I do not consent, no information will be disclosed except as provided by law.

This consent is subject to revocation in writing at any time, but such revocation can
have no effect on disclosures previously made. In any event, this authorization
expires without express revocation upon termination of therapy or on the date indicated below.

Release expiration date: ________________________

_____________________________________ __________________________

Signature of client (or parent/guardian)

Date

_____________________________________ __________________________

Signature of witness

Date

Revised March 24, 2003