Consent for Release of Information

                                Howard K. Gurr, Ph.D.

                                            Psychologist

 I am agreeing to allow Dr. Howard Gurr to communicate, or share information, about myself or my child with  the Practitioners indicated on this form. I understand that I have no obligation whatsoever to disclose the requested information and that I may revoke this consent at any time by informing in writing any of the identified individuals. I further understand that this authorization is valid for a period of 90 days from the date of my signature below.

In consideration of this consent, I hereby release the listed parties from any legal liability resulting from the release of this information.

I understand that information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient of your information and no longer protected by the HIPAA Privacy Rule.