CRT COUNSELING
CHANGE, RENEWAL, TRANSITION
9304 FOREST LANE # 100 SOUTH
(214) 340-0208
FAX: (214) 340-7092
www.crtcounseling.com
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,