I, ________________________________________________________________
Hereby authorise the following organisation(s) or individuals to release any confidential or other information (written or otherwise) that will assist in my treatment.
Please tick authorised party below:
Doctor Name: ________________________________________________________________
Case worker Name: ________________________________________________________________
Insurer Name: ________________________________________________________________
Other Name: ________________________________________________________________
I authorise _______________________ to release information to the above organisation(s) and individuals that will assist with my treatment goals. I understand that all information about me is confidential and cannot be released to another party without my written authorisation.
Client signature: ______________________________________________________ Date: ___________
Please Note: If after reading this page you are unsure of what is written please discuss it with me.