Consent to Release
Receive Information to/from Funders
I (write your FULL NAME in BLOCK CAPITALS)
give permission to Brisbane City Psychologists to obtain/release information from/to the following individuals and agencies. I understand that information will be used to assist in funding of psychological sessions only and will not be passed on to any third agency without permission. This agreement excludes the disclosure of any clinical information gathered in the course of psychological assessment and treatment. I understand that consent can be withdrawn at any time.
e.g. Relative or friend, EAP provider, insurance company
Your Case Manager
Your Funder's Phone Number
Other Third Party
e.g. Lawyers, insurance company or N/A if not applicable.
Date of Agreement
We will send you a copy of this agreement to your email address.
I have understood and agree with the above conditions.
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