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)
Name of Client*
Age*
Date of Birth
MM slash DD slash YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Name of Agency or Institution (if applicable)
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Phone
Fax No
I consent to the following information to be disclosed (Check and initial by each box):
- Telephone consult
- Academic history
- Family history of self or minor
- Psychiatric, psychological or other assessment
- Leave message on contact numbers provided
- Email, Skype or other telecommunication
- Other
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.
Printed Nameof Client
Today’s date
MM slash DD slash YYYY
Printed Name Legal Guardian (if youth is under 16)
Signature of Guardian
Today’s date
MM slash DD slash YYYY

Consent to the Disclosure, Transmittal of Information

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

CONSENT TO THE DISCLOSURE, TRANSMITTAL OFINFORMATION

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Congratulations on being #1 Heidi Spiar!

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