Psychological Service Consent & Exchange of Information Form

Psychological Service Consent & Exchange of Information Form

Child
Name of Child*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender
Parent / Guardian 1*

First NameLast Name
Phone *
Contact Number
Relationship to Child*
Email*
example@example.com
Parent / Guardian 1 Address*

Street Address

Street Address Line 2

SuburbState

Postcode
Parent / Guardian 2

First NameLast Name
Phone
Contact Number
Relationship to Child
Email Address
example@example.com
Parent / Guardian 2 Address

Street Address

Street Address Line 2

SuburbState

Postcode
I / We, {parent4} and {parent}, hereby declare that I am / We are the parent/s or legal guardian/s of {nameOf}.

I / We hereby consent to the psychological assessment / treatment of {nameOf} to be provided by Damien Tuffano Psychology.
I / We hereby give consent for Damien Tuffano Psychology to consult with, receive information from or release information on behalf of Child's Name to the following:
1.   GP
2.   School
3.   Speech / OT
4.   Paediatrician
Signature of Parent / Guardian 1*

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Date signed*

MonthDayYear
Date
Signature of Parent / Guardian 2

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Date signed

MonthDayYear
Date
Should be Empty: