CONSENT FOR RELEASE OF INFORMATION
TO:  ____________________________________
I, ___________________________, born _______________, Social Security Number _______________, hereby authorize and direct you to:
(1) communicate with James B. Gottstein of the Law Project for Psychiatric Rights (PsychRights), 
(2) answer all of PsychRights questions, and 
(3) provide copies of ______________________________ ____________________________ to PsychRights.  
The purpose of this consent is _________________________ 
______________________________________________________.  
I understand that my records are protected under federal confidentiality regulations and cannot be disclosed without my written consent unless otherwise provided for in the regulations.  I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it (e.g. probation, parole, etc.) and that in any event this consent expires at the earlier of ____________, or 180 days from now.
A copy hereof, shall be effective.
Executed this ____ day of ____________, 20___.

__________________________