Consent for Disclosure of Information to Third Parties

Parent/guardian’s full name

Child’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

Other

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

Date Signed

Consent for Disclosure of Information to Third Parties

Referral Form