I give permission for the following person to have contact with my psychologist and the Support Team for any issues related to the administration and practicalities of my appointments (but not health-related information).

    Parent / Friend / Partner / Family Member Full Name/s

    Their phone number

    Their email address

    Relationship to client

    Your full name

    Your email (you will receive an email confirmation of this completed form)

    Yes, I agree to all statements made in this form.