Consent to transfer Client information – The Talk Shop

The Talk Shop and the Cairnmillar Institute (Cairnmillar) have an arrangement whereby suitable Clients who are on the waiting list at The Talk Shop may be referred on to Cairnmillar to be seen at no cost by a suitably supervised Student Clinician either via Telehealth or in person at one of the Cairnmillar Clinics. In order for us to do this on your behalf, we need your written consent.

Contact details for the Cairnmillar Clinics:
Telephone: 1800 391 393 or (03) 9813 3400
Fax: (03) 9804 3333
Email: clinic@cairnmillar.org.au

I*

(Name)

First Last

of*

(Address)

Street Address City State / Province / Region ZIP / Postal Code Country

born on*

(Date of Birth)

Email*

hereby give The Talk Shop permission to forward my referral and Client file to Cairnmillar so that I am able to see a supervised Student Clinician sooner than waiting for a Clinician at The Talk Shop.

I understand that The Talk Shop will close my client file, and all my future Client records will be maintained by Cairnmillar.

I understand that the sessions with the Student Clinician will be free of charge.

If I have queries about my appointments, clinician or need to book or reschedule appointments, I will contact the Cairnmillar Clinic directly.

Signature*