Release of Information Form

I am completing this form: *

For myselfOn behalf of someone else as an authorised representative

Your details

Your first name *

Your surname *

Relationship to the individual receiving service *

First name of the individual receiving service *

Surname of the individual receiving service *

Consent

I consent to the release of information between Windermere and the service and/or practitioner listed below:

I wish to list the following amount of service and/or practitioners:

Name of service and/or practitioner *

Purpose of request *

Name of service and/or practitioner *

Purpose of request *

Name of service and/or practitioner *

Purpose of request *

Name of service and/or practitioner *

Purpose of request *

Name of service and/or practitioner *

Purpose of request *

Name of service and/or practitioner *

Purpose of request *

I consent to this form being distributed to all parties listed above: *

YesNo

If no, a separate form is to be completed for each service/practitioner listed

I DO NOT consent to the release of information between Windermere and the service and/or practitioner listed below: *Note for Victims Assistance Program (VAP) consumers: Windermere is required by the Department of Justice & Community Safety to share information with other VAPs and the Department (through a secure database) to improve service quality and safety.

Please sign here *

Clear

Name *

Date *