AUTHORIZATION AGREEMENT The purpose of this disclosure is to better assist the client in his/her/their mental health treatment. By completing this form I acknowledge that I understand that, unless withdrawn, this authorization will expire 180 days from the date of the electronic signature and submission. A photocopy of this form will be considered as valid as the original. *

I Agree

I Do Not Agree

I understand that I may revoke this authorization at any time by notifying Monya Cohen, Psy.D., LLC at the address indicate above, in writing, and this authorization will cease to be effective on the date notified except to the extent action has already been taken in reliance upon it. *

I Agree

I Do Not Agree

I understand that my refusal to sign this authorization will not jeopardize my right to obtain present or future treatment for psychiatric disabilities except where disclosure of the information is necessary for the treatment. *

I Agree

I Do Not Agree

My health care and payment for my health care at Monya Cohen, Psy.D., LLC, will not be affected if I do not sign this form. *

I Understand

I Do Not Understand

I understand that I can request a copy of this form after I sign and submit it. *

I Agree

I Do Not Agree

Electronic Signature of Patient *

First Name

Last Name

Electronic Signature of Legal Guardian (if applicable)

First Name

Last Name