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CRT COUNSELING

CHANGE, RENEWAL, TRANSITION

9304 FOREST LANE # 100 SOUTH

DALLAS, TX 75243

(214) 340-0208

FAX: (214) 340-7092

www.crtcounseling.net

 

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

 

_______________________________

Date

 

_____________________________________________________________________

Name of Physician/Psychiatrist

 

______________________________________________________________________

  

______________________________________________________________________   

Address                                                    

______________________________________________________________________

Phone Number  

______________________________________________________________________

Fax Number

 

 

 

 

Dear Doctor______________________________,

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.

 

Sincerely,