Release of Information Form

You have been asked to complete this form because your psychologist needs your permission to exchange information about you/your child with certain people in order to deliver the best possible care. If you have any questions or concerns please don’t hesitate to contact Candice on 0455 722 118 or candice@nourishpsych.com.au before signing the form.

I confirm this can be transmitted via digital means and understand this may not be as secure as registered post.

I understand this information is being released for the purpose of therapeutic intervention and/or assessment for appropriate services.