Fill and Sign the Release Authorization Form

Waiver, Release and Authorization to Use a Description of Patient’s Psychological History and Treatment in a Book without Identifying the Name of Patient Agreement executed on _________________ (date) , by ________________________ (Name of Releasor) of ___________________________________________________ (street address, city, county, state, zip code), hereinafter referred to as Releasor or Patient , in favor of ___________________________ (Name of Psychologist) of ______________________________________________ (street address, city, county, state, zip code) herein referred to as Psychologist . Whereas, Psychologist is a duly licensed psychologist and therapist presently practicing in _____________________________ (name of city, county), and is writing or has written a book entitled or to be entitled _______________________________ (Name of Book), hereinafter called Book ; and Whereas, said Book deals with or shall deal with ______________________________ ______________________________________________________________________ ______________________________________ (briefly describe what Book deals with, such as “the diagnosis and treatment of situational depression”); and Whereas, certain aspects of Patient’s psychological history and treatment will be helpful in discussing __________________________________________________________ (e.g., name of subject or malady to be discussed); and Whereas, Psychologist has used or desires to use certain aspects of Patient’s psychological history and treatment in this Book as reflected in Patient’s file presently located at the office of Psychologist at ______________________________________ __________________________ (street address, city, county, state, zip code); and Whereas, neither the name of Patient nor any other specific information such as the address of Patient has or shall be used in this Book, and Psychologist will use his best efforts to keep the identity of Patient confidential; and Whereas, Patient is willing for such information about his/her psychological challenges to be used in this Book without compensation and with no rights in or to Book in order to help others who have similar psychological challenges; Now, therefore, for and in consideration of the mutual covenants contained in this Agreement, and other good and valuable consideration, the parties agree as follows: 1. Releasor hereby expressly releases Psychologist, his publishers, licensees, agents, successors and assigns (hereinafter jointly and severally called Releasees), from all liability for claims and/or demands arising out of the use of the information about Patient as described above, including, but not limited to, libel, slander, invasion of privacy or any other claim based on use of the information about Patient in said Book. 2. Releasor acknowledges and agrees that he/she shall have no rights in said Book or in any revenues generated by the sales of said Book. 3. Releasor also understands and agrees that realize that Psychologist may transfer ownership of this Book or may authorize others to publish the material and that it may appear in articles, medical journals, subsequent editions, and other written forms. 4. Releasor further agree to indemnify and save Releasees harmless from any and all claims and liability for damages, losses or expenses of any sort arising from use of the information about Patient as described above in the writing, making or the publication of said Book. 5. Releasor warrants and agrees that he/she has read and understand the contents hereof, and that he/she has the right and authority to execute this waiver, release and indemnification. In witness whereof, the parties have executed this Agreement as of the date and year first above written. _____________________________ _________________________ (Signature of Psychologist) (Signature of Patient) _____________________________ _________________________ (Printed Name of Psychologist) (Printed Name of Patient)