Client Name
Residential Address

I consent to Pete Lewis Psychotherapy obtaining information from the agencies/individuals listed below, that is considered necessary and relevant to my psychological wellbeing and management. Examples of such information may include medical reports, mental health history, behavioural information, current difficulties, hearing/vision assessments and any other relevant allied health professionals’ reports. This information will be used to better understand you, assist you, and assist with psychological treatment plans.

I consent to Pete Lewis Psychotherapy releasing information to the agencies /individuals listed below, that is considered necessary and relevant to my psychological wellbeing and management. Examples of such information may include psychological reports, diagnoses, behavioural information, mental health history, current difficulties, and support strategies. The information shared will be that to further understand and assist you.

Authority to Sign

NOTE: This authority is valid for twelve (12) months from the date signed.
Clients under the age of 16 will also need Legal Guardian to sign.
Clear Signature