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Therapists
Philadelphia, PA Office
Chris F. Fariello, PhD, MA, LMFT, CST
Jordan Lief, Psy.D.
Erin Seeherman, LPC
CJ Mooney, MFT, CTP (they/she)
Erica Hochanadel, LSW, MEd.
Melissa Sziga Dessereau, MA, LMFT, CST
Meredith Hritz, MFT
Natasha Metzger-Florida, MFT
Sara Kasey Mairs, LSW, MSW
Rebecca Bassman, LMFT
Seneka LaBonde, MEd, LMFT
Nicole Williams, MFT
Naomi Berner, LSW, MEd
Kileen Barry, BA
Samantha Morris, LSW, MEd
Aliyyah Johnson, MFT
Evan Kardon, MFT
Marianna Kopp, MFT
Michella Aken, BA
Media, PA Office
Chris F. Fariello, PhD, MA, CST, CSE, LMFT
Carly Chodosh, LSW
Erica Thomke, LSW, MEd.
Seneka LaBonde, MEd, LMFT
Samantha Morris, LSW, MEd
Virtual Therapists
Chris Wilson, PhD, LMFT, CST
CJ Mooney, MFT, CTP (they/she)
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Authorization for Release of Information Form
Therapist
*
-Choose Your Therapist-
Chris Fariello
Jordan Lief
Chris Wilson
Sziga Dessereau
Erin Seeherman
Erica Thomke
Sara Kasey Mairs
Rebecca
Seneka
Erica Hochanadel
Natasha Metzger
Avi Diamond
Meredith Hritz
CJ Mooney
Samantha Morris
Nicole Williams
Carly Chodosh
Naomi Berner
Kileen Barry
Michella Aken
Evan Kardon
Marianna Kopp
Aliyyah Johnson
I (client) hereby authorize use or disclosure of protected health information about me as described below.
Name
*
First
Last
The following specific person or class of persons or facility is authorized to make the requested use or disclosure:
*
Specific description of information to be released (and date(s) of service):
*
The information to be released will be used for the psychotherapeutic treatment of the client(s) in a manner that is consistently with all ethical and legal guidelines.
I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it, and would then no longer be protected by federal privacy regulations.
I may revoke or withdraw this authorization by notifying my therapist in writing of my desire to revoke it. However, I understand that any action already taken in advance of this authorization cannot be reversed, and my revocation will not affect those actions. I understand that the medical provider to whom this authorization is furnished may not condition its treatment of me on whether or not I sign the authorization.
This authorization will expire on the below date or 1 (one) year after the date of said authorization.
*
Date Format: MM slash DD slash YYYY
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Email
This field is for validation purposes and should be left unchanged.
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