AUTHORIZATION TO USE CASE/INTERVIEW MATERIALS FOR 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/interviews in a general trade book tentatively titled _______________ (hereinafter referred to as the Work).  This letter serves as an agreement between us, according to the following terms: 

You consent to the possible use of transcripts and summaries of your sessions, your interviews and commentaries upon them, or other case material in the Work.  These consents extend to all formats, editions, media, and revisions, and derivative works prepared from the Work, and in the marketing and packaging of such works to the general public, in all languages, throughout the world.  

We will, if you so designate below, take reasonable and customary steps to change or remove data that in our judgment may be likely to enable you to be identified, but you understand that some detail may appear in the Work that could be considered to identify you.  In no event will your name or address be used.  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 uses described in this consent. 

In exchange for your consent, you will receive one free copy of the first English-language print edition of the Work.

There are no agreements between us other than this one, which can be changed only by a signed document.  

Your signature below indicates your consent 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)