Authority to Release Information Form for Children

I,
(Full Name - Required)
, parentguardian (required) of,
(Full Name - Required)

(Date of Birth - Required)

the undersigned, herby authorise the release of information regarding my child's personal contact details, familial / legal / psychological / emotional and/or physical health status, held by Napier House to,

(Check all that apply and provide details)
School

Kinder

DHHS

BDAC

Anglicare

Other Family

Day Care

NDIS

LAC

Support Coordinator

Plan Manager

Physiotherapist

Speech Pathologist

Psychologist

Occupational Therapist

Paediatrician / GP

Other - specify

via

(Check all that apply and provide details)
phone call

report/s

session note/s

session at:

social stories and visuals

other - specify

I confirm that information transmitted via digital means (eg, email / messages) 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.

Signature (Required)

If you have any questions about this please contact reception at (03) 54101011 or reception@napierhouse.com.au.