Consent to Exchange Information With a Third Party

First name

Last name

Parent / Guardian First and Last Name (if client is under 18 years of age)

Phone

Postal or Street Address

I give my consent to Dr Jamie Marshall to obtain or share information with those individuals and organisations nominated below. I understand that the information shared will be limited to that which is relevant to my treatment (or my child's treatment) and/or management of relevant psychological and emotional conditions.

Individual or organisation 1

Individual or organisation 2

Individual or organisation 3

Individual or organisation 4

Individual or organisation 5

I agree and understand that the period of this consent is continuous and ongoing unless I expressly revoke my consent in writing to Dr Jamie Marshall, or unless I place an expiry date for this consent in the box below.

Expiry date for consent (if applicable)

Signature

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