Consent Form

Consent to Obtain/Disclose Information

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"*" indicates required fields

Your Personal Information

First Name*

Last Name*

Child's name (if applicable)

Date of birth*

Phone number*

Email Address*

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.

Name

Role/Profession

Organisation (if applicable)

Contact details

Information to be Obtained/Disclosed

Reason for request

Case consult

Other

If you have selected 'Other', please advise

Declaration/Consent

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.

First name*

Last name*

Signature*

Date*