untitled1 [] · jeffrey perlman, ph.d., i-csw 5300 w. atlantic avenue suite 503 delray beach, fl...

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Page 1: Untitled1 [] · Jeffrey Perlman, Ph.D., I-CSW 5300 W. Atlantic Avenue Suite 503 Delray Beach, Fl 33484 AUTHORIZATION FOR RELEASE OF INFORMATION (Insert Name of Patient/Client), whose
Page 2: Untitled1 [] · Jeffrey Perlman, Ph.D., I-CSW 5300 W. Atlantic Avenue Suite 503 Delray Beach, Fl 33484 AUTHORIZATION FOR RELEASE OF INFORMATION (Insert Name of Patient/Client), whose
Page 3: Untitled1 [] · Jeffrey Perlman, Ph.D., I-CSW 5300 W. Atlantic Avenue Suite 503 Delray Beach, Fl 33484 AUTHORIZATION FOR RELEASE OF INFORMATION (Insert Name of Patient/Client), whose
Page 4: Untitled1 [] · Jeffrey Perlman, Ph.D., I-CSW 5300 W. Atlantic Avenue Suite 503 Delray Beach, Fl 33484 AUTHORIZATION FOR RELEASE OF INFORMATION (Insert Name of Patient/Client), whose
Page 5: Untitled1 [] · Jeffrey Perlman, Ph.D., I-CSW 5300 W. Atlantic Avenue Suite 503 Delray Beach, Fl 33484 AUTHORIZATION FOR RELEASE OF INFORMATION (Insert Name of Patient/Client), whose
Page 6: Untitled1 [] · Jeffrey Perlman, Ph.D., I-CSW 5300 W. Atlantic Avenue Suite 503 Delray Beach, Fl 33484 AUTHORIZATION FOR RELEASE OF INFORMATION (Insert Name of Patient/Client), whose
Page 7: Untitled1 [] · Jeffrey Perlman, Ph.D., I-CSW 5300 W. Atlantic Avenue Suite 503 Delray Beach, Fl 33484 AUTHORIZATION FOR RELEASE OF INFORMATION (Insert Name of Patient/Client), whose
Page 8: Untitled1 [] · Jeffrey Perlman, Ph.D., I-CSW 5300 W. Atlantic Avenue Suite 503 Delray Beach, Fl 33484 AUTHORIZATION FOR RELEASE OF INFORMATION (Insert Name of Patient/Client), whose
Page 9: Untitled1 [] · Jeffrey Perlman, Ph.D., I-CSW 5300 W. Atlantic Avenue Suite 503 Delray Beach, Fl 33484 AUTHORIZATION FOR RELEASE OF INFORMATION (Insert Name of Patient/Client), whose
Page 10: Untitled1 [] · Jeffrey Perlman, Ph.D., I-CSW 5300 W. Atlantic Avenue Suite 503 Delray Beach, Fl 33484 AUTHORIZATION FOR RELEASE OF INFORMATION (Insert Name of Patient/Client), whose
Page 11: Untitled1 [] · Jeffrey Perlman, Ph.D., I-CSW 5300 W. Atlantic Avenue Suite 503 Delray Beach, Fl 33484 AUTHORIZATION FOR RELEASE OF INFORMATION (Insert Name of Patient/Client), whose
Page 12: Untitled1 [] · Jeffrey Perlman, Ph.D., I-CSW 5300 W. Atlantic Avenue Suite 503 Delray Beach, Fl 33484 AUTHORIZATION FOR RELEASE OF INFORMATION (Insert Name of Patient/Client), whose
Page 13: Untitled1 [] · Jeffrey Perlman, Ph.D., I-CSW 5300 W. Atlantic Avenue Suite 503 Delray Beach, Fl 33484 AUTHORIZATION FOR RELEASE OF INFORMATION (Insert Name of Patient/Client), whose
Page 14: Untitled1 [] · Jeffrey Perlman, Ph.D., I-CSW 5300 W. Atlantic Avenue Suite 503 Delray Beach, Fl 33484 AUTHORIZATION FOR RELEASE OF INFORMATION (Insert Name of Patient/Client), whose
Page 15: Untitled1 [] · Jeffrey Perlman, Ph.D., I-CSW 5300 W. Atlantic Avenue Suite 503 Delray Beach, Fl 33484 AUTHORIZATION FOR RELEASE OF INFORMATION (Insert Name of Patient/Client), whose
Page 16: Untitled1 [] · Jeffrey Perlman, Ph.D., I-CSW 5300 W. Atlantic Avenue Suite 503 Delray Beach, Fl 33484 AUTHORIZATION FOR RELEASE OF INFORMATION (Insert Name of Patient/Client), whose