Document Releases
[ ] By checking box I give my permission for the copying and distribution of “Background Information For Case Evaluation,” and any other materials provided, to additional thought reform consultants, and/or mental health professionals, and/or ex-members, and/or others for the purposes of evaluation and preparation.
[ ] By checking the box, I understand that any documents (forms, pictures, books, and audio/visual) will not be returned. Please send copies only.
Research Release
[ ] By checking the box I give my permission for the copying and distribution of “Background Information For Case Evaluation,” and any other materials provided, for the purposes of follow up and research and development.
Date:_______________________
Name:______________________
Signed: _____________________
(When sending via email, type your name and the word "signed".)
CONTACT INFORMATION
Send "Release" form via Mail or e-mail to:
Intervention101
Joseph Kelly/ Patrick Ryan
1300 S. 13th Street
Philadelphia, PA 19147
Phone: 215.467.4939;
e-mail: cultintervention@gmail.com;
http://www.intervention101.com/
