"…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
