![](https://cdcssl.ibsrv.net/ibimg/smb/200x158_80/webmgr/1a/f/c/phpthumb-generated-thumbnail-7.jpg.webp?2d0ef0325f477f36002d5272f754d75d)
![](https://cdcssl.ibsrv.net/ibimg/smb/200x158_80/webmgr/1a/f/c/jumping-12979335small.jpg.webp?2d0ef0325f477f36002d5272f754d75d)
If you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), complete this form to authorize release of psychotherapy information:
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