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Consent To Release Information Form Psychology
"I need a Consent To Release Information Form Psychology that allows my therapist to share specific assessment results with my workplace occupational health team for the next 6 months, starting from January 2025, with particular emphasis on maintaining confidentiality of personal details."
1. Client Information: Personal details of the individual whose information is being released
2. Provider Information: Details of the psychological service provider/practitioner
3. Information to be Released: Specific description of what information is authorized for release
4. Recipient Information: Details of who is authorized to receive the information
5. Duration of Consent: Time period for which the consent remains valid
6. Rights Statement: Information about the right to withdraw consent and data protection rights
7. Signatures: Space for client and witness signatures with dates
1. Capacity Assessment: Section confirming capacity to consent, used when there are concerns about mental capacity
2. Third Party Authorization: Used when someone other than the client is providing consent (e.g., parent, guardian, power of attorney)
3. Specific Exclusions: Section detailing any information specifically excluded from the release authorization
4. Emergency Contact: Additional contact information for urgent situations
1. Privacy Notice: Detailed information about how personal data will be processed
2. List of Records: Itemized list of specific documents/records to be released
3. Capacity Assessment Form: If required, detailed documentation of capacity assessment
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