Release of Confidentiality Form

I, , am currently a patient of Dr. Winston Wilde.

I wittingly and willfully consent to give permission to Dr. Wilde to professionally discuss my case with , .

I agree that Dr. Wilde may discuss with the above named person any and all information I may have revealed to him in the course of treatment, as well as any opinions, diagnoses, and interpretations he may have concerning me and my psychotherapy treatment.

This agreement will be valid for one year from the date indicated below. I may revoke this release at any time by submitting a written revocation to Dr. Wilde.

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