Release of Confidential Information

Release of Confidential Information Form

PLEASE SELECT CLINIC LOCATION:

FTG Clinic Boronia Clinic

I give permission for: (professional’s name, and agency’s name if relevant)

To Contact: (name of other professional, and agency’s name if relevant)

To provide and/ or obtain information regarding:

Client's Name

DOB:

Address

I give permission for the following information to be shared:

Please tick relevant box:

Any relevant information to conduct handover

Copy of Mental Health Care Plan / Referral- if digital copy available to reception

Number of sessions already used in current calendar year.

Other. please specify:

This information will be used to assist in planning future treatment goals and therapy for the client.

This information will be recorded in the client’s file and will remain confidential.

Reason for change of psychologist(if applicable):

Are other professionals currently involved in working with the client?

Yes No

If yes, specify who these are

Client Name:

Date: