CHANGE, RENEWAL, TRANSITION
9304 FOREST LANE # 100 SOUTH
FAX: (214) 340-7092
At CRT Counseling we believe that coordination of care is very important. We would like to be able to do this with your Primary Care Physician or with your Psychiatrist. In order to do so, we need your permission. By signing below, you authorize CRT Counseling to release any relevant clinical information to the Doctor listed below.
Client Name (please print) Client Signature
Name of Physician/Psychiatrist
This is being sent to you as a courtesy, to inform you that the above named patient is participating in outpatient psychotherapy for ___________________________________.
If you would like to discuss this, please feel free to contact me.