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Therapists
Philadelphia, PA Office
Chris F. Fariello, PhD, MA, LMFT, CST
Melissa Sziga Dessereau, MA, LMFT, CST
Kaitlin DiGiacinto, LMFT
Carly Goodkin, MFT
Jordan Lief, Psy.D.
Erin Seeherman, LPC
Anna Stewart, MFT
Anna Vresilovic, MSEd, LPC
Chris Wilson, PhD, LMFT, CST
Coty Nolin, MFT
Erica Hochanadel, BA
Sara Kasey Mairs, LSW, MSW
Rebecca Bassman, MFT
Seneka LaBonde, MEd, LMFT
Natasha Metzger, MFT
Media, PA Office
Chris F. Fariello, PhD, MA, LMFT
Chris Wilson, PhD, LMFT, CST
Coty Nolin, MFT
Erica Thomke, LSW, MEd.
Sara Kasey Mairs, LSW, MSW
Seneka LaBonde, MEd, LMFT
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Authorization for Release of Information Form
Therapist
*
-Choose Your Therapist-
Chris Fariello
Jordan Lief
Chris Wilson
Melissa Sziga Dessereau
Erin Seeherman
Anna Vresilovic
Kaitlin DiGiacinto
Carly Goodkin
Anna Stewart
Erica Thomke
Sara Kasey Mairs
Seneka Rupert
Rebecca Bassman
Erica Hochanadel
Coty Nolin
Natasha Metzger
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
Comments
This field is for validation purposes and should be left unchanged.