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 Name Last Name
Date of Birth

Day Month Year
Date Date Picker Icon

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Services
Name

First Name Last Name
Phone Number

Area Code Phone Number
Service
Email
example@example.com
Name

First Name Last Name
Phone Number

Area Code Phone Number
Service
Email
example@example.com
Name

First Name Last Name
Phone Number

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

First Name Last Name
Date

Day Month Year
Date Date Picker Icon
Signature

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