"…of a different mind"
Email rogernmeyer@earthlink.net
Phone/FAX 503-666-2776
Cell: 503-358-6463
18162 E Burnside
Portland, OR 97233
AUTHORIZATION FOR DISABILITY
ADVOCACY
I, __________________________________________________, hereby authorize Roger N. Meyer, DBA "…of a different mind" to be my disability advocate with the agency or the professional listed below.
Mr. Meyer is authorized to conduct conversations and official business relating to my disability with the person(s) and agency listed below.
This authorization is effective as of the date of my signature, and can be revoked by me at any time. If my case is transferred to another agent or professional within the agency, this agreement shall remain in force. Absent my revocation, this authorization and release will remain in effect for ninety days following the closing of my case and/or file with the agency.
PERSON OR AGENCY___________________________________________________
Professional or agency address_____________________________________________
Purpose of consultation/contact_____________________________________________
________________________________________________________________________
X________________________________________ Date_______________________
(SIGNATURE)
__________________________________________
ROGER N. MEYER
Student and Adult Disability Advocacy Professional In-Service Education Case Management
Consultant on Non-Verbal Learning Disabilities, Asperger Syndrome and High Functioning Autism
