The Snowflake Clinic

Consent To Exchange Information With A Third Party

I give my consent to The Snowflake Clinic to obtain or share information with those individuals and organisations nominated below. I understand that the information shared will be limited to that which is relevant to my (or my child's) treatment and/or management of relevant psychological and emotional issues.

I agree and understand that the period of this consent is continuous and ongoing unless I expressly revoke my consent in writing to The Snowflake Clinic.

Clear signature

Thank you for completing this form. When finished, please click or tap the Submit button below and your responses will be sent through to The Snowflake Clinic.