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 Napier House 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 (someone I am legally responsible for). Their name is:
Signature (Required)
If you have any questions about this please contact reception at (03) 54101011 or reception@napierhouse.com.au.
