Consent to the Disclosure, Transmittal of Information

  • HEIDI SPIAR, M.A.R.P. PRIVATE PRACTICE

    CONSENT TO THE DISCLOSURE, TRANSMITTAL OFINFORMATION

    This form is used if a client wishes information to be shared between Heidi Spiar and another person, professional or agency.

  • I give permission for the sharing of personal information(check all that apply) relating to myself ( if minor, to my child),between Heidi Spiar and person(s), professionals/agency as indicated below on this form. (one form per contact)
  • Date Format: MM slash DD slash YYYY
  • I consent to the following information to be disclosed (Check and initial by each box):
  • I understand that the sharing of information will be used to support counsellingand will not be shared with any agency or person not named on this form. I also understandthat suspected abuse require mandated reporting to the local protection welfare agency/or Police and fall outside of this agreement.

    I understand that I have the right to revoke or change this authorization with written notice to the provider.

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY