Page 93 - Meeting with Children Manual

P a g e | 3 Referral and Release of Information

File Number ________________________

CONSENT TO THE RELEASE OF INFORMATION:

I ______________________________________________________ of

___________________________________________________________, agree that:

1. I am a client of ISDR Pty Ltd engaging in a Family Dispute Resolution process with Jon
Graham (FDRP).
2. I am the parent/guardian of:

 ______________________________ (child 1) ____________ (DOB)
 ______________________________ (child 1) ____________ (DOB)
 ______________________________ (child 1) ____________ (DOB)
 ______________________________ (child 1) ____________ (DOB)
3. As part of the Family Dispute Resolution process it has been identified as necessary for the
release to the professional listed below the following information:
 My name and contact details.
 My children’s name and contact details.

 A statement to the other professional of the purpose of the Family Dispute
Resolution process.
4. The FDRP shall provide information to the professional listed below, which outlines the
nature of services required and such other information as deemed necessary by the FDRP in
order to make the services requested as effective as possible.
5. I understand that I can withdraw this consent to the release of information at any time, by
verbal request conformed by a written or emailed confirmation.

Professional to whom information is released:

Name: ______________________________________________________________

Location: ___________________________________________________________

Role: _______________________________________________________________

Signed:

____________________________ ______________________________
(Parent) (Practitioner)

(Date)

© Lorri Yasenik and Jon Graham 2016
Private and Confidential
We acknowledge and pay respect to the traditional owners and custodians of the land on which we work and live.
The Institute of Specialist Dispute Resolution Pty Ltd
ABN 46 105 820 791
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