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"…of a different mind"

Email rogernmeyer@earthlink.net

Phone/FAX 503-666-2776

Cell:  503-358-6463

18162 E Burnside

Portland, OR  97233

 

 

RELEASE AND AUTHORIZATION FOR ADVOCACY AND PERSONAL REPRESENTATION

 

 

 

I,__________________________________________________, hereby authorize Roger N. Meyer, DBA "…of a different mind" to be my advocate/personal representative with the agency or the professional listed below.

 

Mr. Meyer is authorized to conduct conversations and exchange correspondence with my caseworker/counselor/professional.  Mr. Meyer is further authorized to attend any staffing conferences and other multidisciplinary team meetings where my case and/or issues are being discussed.

 

 

This release and authorization is effective as of the date of my signature, and can be revoked by me at any time during the time I maintain a relationship with the agency or professional.  If my case is transferred within the agency, this agreement remains in force.  Absent a revocation, this authorization and release will remain in effect whether my case is active or inactive with the person or agency identified below.

 

 

PERSON OR AGENCY___________________________________________________

 

Professional or agency address_____________________________________________

 

Purpose of consultation/contact_____________________________________________

 

________________________________________________________________________

 

 

 

___________________________________                                                  ____________

                        Signature                                                                                        Date

 

 

___________________________________                                                  ____________

                ROGER N. MEYER                                                                             Date

 

 

 

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