Patient Identification & Consent Form (Page 3 of 3) in pdf

Dr Mathew McCauley, Consultant Clinical Psychologist

Suite 13, Blackrock Clinic, Rock Road, Blackrock, County Dublin, Ireland

Tel: 01-2064217; Fax: 01-2780354

RELEASE OF INFORMATION

The purpose of the following details are to authorize the release of information of your mental health care, both verbal and written,

between Dr McCauley’s office and certain healthcare professionals, these other professionals might include mental health clinicians,

substance abuse workers, state-bodies, and so on. This release excludes communication between Dr McCauley and your GP and/or the

provider that referred you to this service, as such correspondence is standard clinical practice. As outlined earlier, continuity of care is

important in providing safe and professional psychological services.

Mental Health Clinician (Name/Address/Phone)

______________________________________________________________________________________________

Substance Abuse Worker (Name/Address/Phone)

______________________________________________________________________________________________

Other (Name/Address/Phone)

______________________________________________________________________________________________

Other (Name/Address/Phone)

______________________________________________________________________________________________

Summary of the information being released to the above individual(s):

I authorize Dr McCauley’s office to communicate with the above persons and/or agencies in support of my care. I understand that I

may revoke this authorization at any time by giving written notice to Dr McCauley’s office except to the extent regarding actions that

have already been taken. As such, this release will remain active until revoked in-writing by me (the patient). I also understand that

this authorization does not relate to communication between Dr McCauley’s office and my GP and/or referring provider, as such

correspondence will occur as part of standard professional practice.

Patient’s Name:____________________________ Patient’s Signature:__________________________ Date:____________________

Patient Identification & Consent Form Page 3