Authority to Obtain and Release Information

Authority to Obtain and Release Information
United Minds/Rubix Centre provides a holistic service and in order to provide you with the most appropriate support, we may need to talk to service providers, teachers, parents, government bodies or other persons. The information obtained and released will pertain to your treatment or to information that will assist the Psychologist in providing you with the most appropriate support.

By signing this form, I agree to give United Minds/Rubix Centre permission to obtain and release information about/for my treatment/assessment with:
Client Name

First NameLast Name
Details of Person we are Contacting

Persons Full Name

Organisation they work for (if relevant)

phone or email Phone Number (if applicable)

Fax (if applicable)
Parent/Guardian Name (if applic.)

First NameLast Name
Client/Parent or Guardian Signature

Clear
Should be Empty: