Consent to Transfer Information Externally

3/35 Grey Street

PO BOX 1741

TRARALGON VIC 3844

Phone: (03) 51764374

Email: admin@thinkgrowconnect.com.au

ABN: 47 166 008 288

CONSENT TO TRANSFER INFORMATION EXTERNALLY

Client's First Name: *

Client's Last Name: *

Client's Date of Birth: *

Parent/Guardian's First Name (if client is a minor):

Parent/Guardian's Last Name (if client is a minor):

Clinician's Full Name: *

CONSENT TO TRANSFER INFORMATION OUTSIDE THINK.GROW.CONNECT

To protect your right to privacy, I request your permission for the transfer of relevant and confidential information to and from authorised professionals involved in the provision of care services that you may require.

I hereby agree that, in regard to the coordination and/or provision of health and personal services care, relevant personal information I have provided to think.grow.connect, can be transferred and discussed with the below individuals.

Please list below the contact details for all individuals you wish to provide consent for:

(Please note: this is the person outside of think.grow.connect that you wish for us to connect with)

Individual's Full Name *

Organisation *

Best Contact Number

Email

I accept that in some instances, think.grow.connect may need to contact the above professionals via email. Client's full names or personal details will not be shared via email communications.

YesNo

I have read and understood the information in this consent form and have discussed any outstanding questions with the practice/psychologist. I agree to the above conditions for consent to transfer information within think.grow.connect.

YesNo

Signature *

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Today's date *

Please note: If, after reading this form you are at all unclear about any of the information provided, please contact the practitioner prior to your appointment.