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info@e-carrington.org
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Home
About
Services
Senior Citizen Case Management & Advocacy
Military / Veteran Advocacy
Clinical Mental Health Services
Car Donation & Gifting Program
Donation
Forms
Rates/Fees
Contact
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By Appointment Only
(703)789-0979
703-530-9805
info@e-carrington.org
9300 Forest Point Circle 154
Manassas, VA 20110
*Times are subject to change. Please contact our office with your scheduling questions.
PERSONAL INFORMATION
Name
Home Phone
Cell Phone
Email Address
I authorize
Actions
To send the following information to
To receive the following information from
Authorized Personnel
#1
Name
Address
#2
Name
Address
#3
Name
Address
Items to be released (check all that apply)
Academic testing results
Case notes
Medical reports
Progress reports
Summary reports
Intelligence testing results
Behavior program
Personality profiles
Vocational testing results
Entire record
Psychological reports
Service plans
Other
The above information will be used for the following purposes:
Planning appropriate treatment or program
Continuing appropriate treatment or program
Case review
Determining eligibility for benefits or program
Updating files
Other
I understand that I may revoke this consent at any time by providing written notice, and after one year this consent automatically expires. I have been informed what information will be given, its purpose, and who will receive the information.
Client's Digital Signature
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