In order to complete a thorough assessment it may be necessary to consult with outside parties. This contact can only be initiated with written permission. Please outline below any relevant individuals or organisations that you consent for Jo Knight Psychology to consult with. This may include other family members, educators/educational facilities, GP’s, Specialists and other allied health professions or specific health care departments.

I,    First Name*   Last Name*   am the legal guardian of   First Name*   Last Name* and give permission for Jo Knight Psychology to consult with, receive information from, or release information to the following stakeholders in relation to the assessment of    First Name*   Last Name*.

Relevant Individuals or Organisations that can be contacted:

1. Name: First Name   Last Name   
Relationship with Client:   Relationship 
Contact Details:   Email/Number or Both   

2. Name: First Name   Last Name   
Relationship with Client:   Relationship 
Contact Details:   Email/Number or Both   

3. Name:  First Name   Last Name   
Relationship with Client:   Relationship 
Contact Details:   Email/Number or Both   

4. Name:  First Name   Last Name   
Relationship with Client:   Relationship 
Contact Details:   Email/Number or Both  







Child's Full Name:   First Name*   Last Name*   
Child's Date of Birth:   Date*   
Parent/Legal Guardian's Full Name:   First Name*   Last Name*   
Parent/Legal Guardian's Phone Number:      Phone Number*   
Relationship with Child:   Relationship*