Consent for Disclosure of Information to Third Parties

Parent/guardian’s full name

Child’s date of birth

I, , the parent/guardian of (child’s date of birth), hereby consent to the disclosure of the below information regarding the above-named child's therapy/counselling sessions to the following third parties if/when required:

I consent to information being disclosed to the following third parties: (Check the relevant boxes to indicate your consent)

School Teachers / Early Learning Educators

Child Safety Officers / Case Workers

NDIS / NDIA Plan Managers

Disclosed Members of the child’s Care Team

I consent to the following information being disclosed to the third parties indicated above: (Check the relevant boxes to indicate your consent)

Medications & Diagnosis

Family Functioning

Behavioural Needs & Challenges

Child’s Notes / History

Parenting Arrangements / Plans

Information Regarding Court Orders

General ObservationsItem 1

Progress / NDIS / NDIA Reports

Child’s Progress

Are there any court orders currently in place?

Yes

Is there anyone you don’t want us to share information with?

Yes

If yes, please provide details below

I understand that the information disclosed will be relevant to the child's care and will be shared solely for the purpose of promoting the well-being and development of the child. I acknowledge that I have the right to revoke this consent at any time by providing written notice to:

Practitioner’s Name

at Playtonomy Pty Ltd.

I consent to the disclosure of information to third parties as described/indicated above.

Parent/Guardian Signature

Protected by reCAPTCHA. Privacy • Terms

Parent/guardian’s full name

I understand that Playtonomy may use artificial intelligence (AI) tools such as ChatGPT to assist in writing clinical notes or reports related to my child’s care.

I acknowledge that:

All personal identifying information, including my child’s name, will be removed before any information is processed by AI.
AI will only be used to assist in drafting documents; all final content is reviewed and approved by qualified clinicians.
My consent is voluntary, and I can withdraw it at any time by informing the service.
The use of AI is intended to improve efficiency but does not replace clinical judgment or personalized care.

I give permission for Playtonomy to use AI tools for my child’s clinical documentation.

Consent for Disclosure of Information to Third Parties

Referral Form