Disclosure | CRTSS

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15 MIN. FREE CONSULTATION

Permission to disclose health related information

First name

Email

Full name of practitioner who is releasing health-related information

Last name

Phone

I give permission for this practitioner to disclose information about my psychological consultations with the following individual and/or organisations:

By ticking this box, I verify that the statements made in this form are correct.

Thank you! We’ll be in touch.

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