Release of Information Form Authority to Release Information 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. I am signing this on behalf of a dependent person (child, adult I am legally responsible for). Their name is: Signature (Required) If you have any questions about this please contact reception at (03) 54431090 or firstname.lastname@example.org. (You might need to press the "Send" button twice depending on your browser - the page will confirm if the message has been sent).