AUTHORIZATION TO USE CASE MATERIAL FOR PROFESSIONAL PUBLICATION AND RESEARCH 

THIS IS A CONSENT AND RELEASE -- PLEASE READ CAREFULLY. 

Thank you for allowing me to use case material from your psychological treatment in a publication intended primarily for the audience described below (hereinafter referred to as the Work). This letter serves as our complete agreement. 

You consent to the possible use of transcripts of your sessions or other case material in the Work.  

In no event will your name or address be used. If you so direct below, I will take reasonable and customary steps to change or remove data that in my judgment may be likely to enable you to be identified, but you understand that despite these efforts some detail may appear in the Work that could be considered to identify you.   The use of this material is limited to clinical research and publication intended primarily for professionals in mental health and behavioral science. 

Neither I, nor the Publisher of the Work, nor anyone engaged to perform services with respect to the Work shall be liable to you for any matter arising out of the participation described in this consent. 

There are no agreements between us other than this one.  This agreement can be changed only by a signed document.  You understand that my publisher and I will be relying upon this release in proceeding to publication, and you should therefore consider it carefully.

Your signature below indicates your agreement to the above terms.  Please sign both copies and return one to me, keeping the other for your records.  Thank you for your participation in this project. 

__________________________________          ___________________________________ 
(Signature)                                                	(Street Address) 

__________________________________          ___________________________________ 
(Name -- please print clearly)                             (City, State, Zip) 

__________________________________           ___________________________________ 
(Date)                                                       	(Phone number) 

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(Name of Clinician)                                        	(Signature of Clinician) 

CHECK IF "YES" 
(   ) Detail deemed to be identifying to be changed or deleted 

_________________________________ 
(signature) 

If under age 21, or otherwise deemed to be necessary or advisable: 

_________________________________          ___________________________________ 
(Name of Legal Guardian)                                (Signature of Legal Guardian)