Consent Form

Consent to Obtain/Disclose Information

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Your Personal Information

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Authorised Person/Organisation

Please enter the details of the person or organisation that you wish to provide consent for Light Mind Counselling PTY LTD and Psychology to obtain/disclose information to. This could be your general practitioner (GP), psychiatrist, case worker, lawyer, or anyone else who you would like involved in your treatment.

Information to be Obtained/Disclosed

Reason for request


I understand that I can cancel this consent at any time by notifying Light Mind Counselling PTY LTD. I have been informed what information has been requested/will be disclosed, its purpose and who will receive the information. I agree to the information as outlined being shared.

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