Authority to Obtain Information Disclosure Form

Authority to Obtain Information Disclosure Form

  • At Sutherland Shire Psychology the privacy of our clients, and the confidentiality of their records, is of utmost importance. We will not request any personal information from a third party without your permission. As such, your psychologist is seeking your written consent to obtain information about yourself or your child from a third party, as part of the service they are providing to you. Please provide the necessary details and permission below.

    Please note: If your psychologist is required to meet (in person or over the phone) or correspond in writing, with a third party, their time will attract a fee, charged in accordance with Sutherland Shire Psychology’s standard hourly rates.

    Please fill in the required information for the third party below.
  • In the space below, please briefly outline which information that would you like Sutherland Shire Psychology to request from the third party.
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