Consent to Share Information

Consent to Share Information
At Riv Hub, we value the confidentiality of all clients. As an Allied Health, we follow the Code of Ethics, mandated by the Australian Health Practitioner Regulation Authority.

Riv Hub will not release any information obtained in the course of your psychological care unless one of the following occurs :-
- We have your informed consent or the consent of a person with legal authority to act on your behalf.
- Where there is a legal obligation to do so.
- If there is immediate and specified risk to an identifiable person
This form provides Riv Hub consent to contact the following people or agencies involved in your care. This consent can be revoked at any time by contacting us.
Client Name

First NameLast Name
Date of Birth

DayMonthYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Services
Name

First NameLast Name
Phone Number

Area CodePhone Number
Service
Email
example@example.com
Name

First NameLast Name
Phone Number

Area CodePhone Number
Service
Email
example@example.com
Name

First NameLast Name
Phone Number

Area CodePhone Number
Service
Email
example@example.com
For clients under 16 years, Parents or caregivers to sign
Name (Client or carer)

First NameLast Name
Date

DayMonthYear
Date
Signature

Clear
Should be Empty: