This form authorizes Ontario Therapy and/or Naomi Barnes, MA, RP, to release, obtain, or exchange personal health information for the purpose(s) identified below.
Personal health information may include information related to assessment, treatment, attendance, recommendations, or other information relevant to psychotherapy services.
Your privacy and confidentiality are important. Information will only be shared with the individuals or organizations identified in this form and only to the extent necessary for the stated purpose, unless otherwise required by law.
Please review this form carefully before signing. You may ask questions about the information being shared, refuse consent, or withdraw your consent at any time by providing written notice, subject to legal or contractual limitations and any disclosure already made in reliance on this authorization.
Type of Authorization
I Authorize: (check all that apply)
Person / Organization
I agree to allow the following contact information to be shared within my letter of support:
Information Authorized for Release
Check all that apply:
Purpose of Disclosure
Check all that apply:
Method of Disclosure
Check all that apply:
Parent / Guardian Consent for Minors
Complete only if signing on behalf of a minor client. Leave blank if not applicable.
Authorization to Release Information
I authorize Ontario Therapy and/or Naomi Barnes, MA, RP, to release, obtain, or exchange the personal health information described above in accordance with my directions in this form. I understand that this authorization is voluntary and that my personal health information is protected under applicable Ontario privacy legislation, including PHIPA. I understand that only information reasonably necessary for the identified purpose will be disclosed. Information disclosed pursuant to this authorization may no longer be protected once received by the recipient and may be subject to re-disclosure, depending on the recipient's privacy obligations and applicable laws.
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