This form is for you to give me consent to share information about you. Please read it carefully and feel free to ask me any questions, or raise any concerns before deciding to submit it. Thank you.

​

Purpose of sharing information about you:

I have emailed you a report of our work together, as we have agreed to ask for additional sessions to be funded by your insurance provider. In order to justify this, they require information about our work together so far, including your symptoms, progress and how I see us using the extra sessions, as well as any mitigating circumstances.

​

If you submit this form:  I will share the report with your insurance provider, so that they can consider our application. I will inform you of their decision either by email or during our next session. I cannot share your information without your consent. I will destroy the report if you do not consent to my sharing it.