Release of Information Form

    I, (Full Name - Required)

    (Date of Birth - Required)

    the undersigned, herby authorise the release of information regarding my personal contact details, familial / legal / psychological / emotional and physical health status, held by Clinical Psychology Victoria to,

    (Person we are sending the information to - Required)

    This person is my (how are they related to you or your dependent (eg - psychologist/doctor/lawyer - Required)

    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.

    Their name is:

    If you have any questions about this please contact reception at (03) 54431090 or reception@cpvic.com.au.

    (You might need to press the "Send" button twice depending on your browser - the page will confirm if the message has been sent).