Lindsay Mayott, Ph.D.

Address: 751 E Blithedale Ave, #58
Mill Valley, CA 94942

Phone: (415)594-5241

Email: lindsaymayottphd@gmail.com

Website: www.lindsaymayottphd.com

AUTHORIZATION TO RELEASE INFORMATION

Client Name:

Date of Birth:

I understand that the purpose of this release is to allow for communication between Dr. Mayott and other care providers or individuals relevant to my treatment. By signing this release, I authorize Dr. Mayott to send / receive (circle one) the following information:

— Medical history and evaluation(s)

— Mental health evaluations

— Developmental and/or social history

— Educational records

— Progress notes, other treatment/evaluation records, and treatment or closing summary

— Relevant diagnostic and treatment information

— Other, please specify:

I authorize Dr. Mayott to release this information to the following individuals/agency:

Name(s)/Agency:

Email:

Phone:

Mailing Address:

The above information will be used for the following purposes:

— Planning for appropriate treatment or program

— Continuing appropriate treatment or program

— Determining eligibility for benefits or program

— Case review

— Updating files

— Other, please specify:

I understand that this authorization is voluntary and I may revoke this authorization at any time, except to the extent that it has already been acted upon. Otherwise, this authorization will expire exactly one year from the undersigned date.

I have been informed what information will be given, its purpose, and who will receive the information. I understand that I have a right to receive a copy of this authorization. I understand that I have a right to refuse to sign this authorization.

Your relationship to client:

— Self

— Parent/legal guardian

— Personal representative

— Other, describe:

Signature:

Date:

Witness Signature (if client is unable to sign):

Witness date: