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AUTHORITY TO RELEASE AND GAIN INFORMATION

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.