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Release of Information Form

Authority to Supply and/or Request Information

First Name

Last Name

Date of Birth

I hereby give premission to Amity Community Services Inc. to supply, an/or request information concerning myself to/from:

Please list all relevant organistions, government departments, health care providers, and/or persons. Eg. GP, family member(s), employer, Top End Mental Health Services/Tamarind Centre Centrelink, lawyer, corrections, ect.:

Please include any limitations to the details or type of information you would like Amity to share, such as 'attendance only', 'counselling focus only', 'progress only', etc:.:

For the period beginning

For the period ending

Please note: This form can be changed, extended or cancelled at any time. Please inform your counsellor if you would like to make any changes to the people or agencies listed above.

Signature

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Client name

Date

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