New Adult Patient

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New Child Patient (under 14)

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Release of Information

hereby authorize:  

Delaware Psychological Services 

16287 Willow Creek Rd. 

Lewes, DE 19958 

302-703-6332 

To release and/or obtain, the following information  

• Mental health and medical history, including diagnosis 

• Records of outpatient treatment 

• All diagnostic, psychological assessment 

• Academic records including grades and standardized testing scores 

This information is to be released for the following purpose(s): 

• Treatment planning & coordination of behavioral health services 

• Third party billing 

• At the request of the individual, parent or authorized agent 

• Forensic Evaluation – I understand that my authorization to release the results of the evaluation may present favorable or unfavorable implications related to the assessment findings and/or recommendations.  I have been informed of the risks pertinent to participation in a forensic evaluation during my initial appointment.   

You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "Submit" you consent to be legally bound

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Credit Card Authorization

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