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Authority to Disclose Information

Client Consent for Therapist / Practitioner to discuss and/or disclose relevant information to nominated third party/s and health care professionals.
  • Date Format: DD slash MM slash YYYY
    Date of Birth
  • Your residential address
  • Name of practitioner & primary qualification. (ie J. Smith, psychiatrist)
  • Authority to release information to:

    Discuss with & release records relevant to and in the best interests of my care on this occasion only and/or as explained in confidence to me by my practitioner. with the following practitioner/s or organisation/s
  • i.e. Renee Chanelle, RTT practitioner)
  • Please provide: practice name, mobile or phone number & email address.
  • Name/s of your practitioner & primary qualification. (ie Dr Mary Jane, GP) - and phone, email contact details for each.
  • Authority

    I confirm that I am over the age of 18, and acknowledge that information may be discussed or conveyed between the people or practitioners mentioned on this form in the best interest of my care and treatment.
  • Date Format: DD slash MM slash YYYY
  • Please provide Full Name & Contact Details of the person witnessing you complete this form (Note: this person may need to verify that you completed this form yourself in court, if necessary).
  • This field is for validation purposes and should be left unchanged.