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Release of Information
Nicole Pray
2023-12-11T09:06:13+12:00
Release of Information
1. I, (please enter your name below:)
(Required)
2. Authorize:
(Required)
Please select relevant team member
Dr Nicole Pray
Ian 'Bish' Bishop
Heather Stevenson
3. To:
release
request
4. confidential information regarding:
myself
my child (list names)
5. If confidential information regarding a child is to be exchanged, I certify that I am the child's:
parent
legal guardian
Name of Child(ren)
Add
Remove
6. Information to be exchanged with:
Name
Address
Street Address
City
State / Province / Region
Postal Code
Email Address
Phone
Fax
7. The information to be exchanged includes (check all that apply):
medical/psychiatric records
treatment summary
school records/teacher observations arrest records
progress notes
diagnoses / background info
psychological report
custody/visitation records
other (specify)
Select All
Other (Specify)
8. The purpose for the exchange of confidential information:
treatment planning
psychological evaluation
child custody evaluation
case planning
parent coordinator services
other (specify)
Select All
Other (Specify)
9. This consent expires on: (1 year from todays date)
DD slash MM slash YYYY
10. Signature
(Required)
Date
DD slash MM slash YYYY
Would you like a copy of this form emailed to you?
Yes
Which email address should we send the form to?
