Use this form to request the release of clinical records, reports, or relevant information from your file to a third party, such as a GP, specialist, school, workplace, insurer, or other health professional.

Requests for file release must be made by the client, or by a person with the legal authority to act on the client’s behalf. Appropriate written consent and full payment of the invoice is required before any information can be released.

Please note that file releases are subject to professional, ethical and legal obligations, including privacy legislation and clinical judgement regarding what information is appropriate to share. Some requests may require clarification, and processing timeframes may vary depending on the nature and volume of the information requested.

Once submitted, your request will be reviewed and actioned in line with our clinic’s policies. Once authorised, we will email you a File Release Consent Form to complete along with an invoice for payment. The total fee invoiced before the file is released will be determined by the size of the file to be released.

All file releases incur a file release fee for all clients and third parties, and we cannot proceed with actioning file release requests without this form being completed first. We do not accept file release requests sent to us via email.

File Release Request

Who is completing the form? *

I am the client

I am a parent / legal guardian completing this on behalf of a client

I am a third party (e.g., GP, psychiatrist, school, solicitor, insurer, employer)

Other (please specify)Other (please specify)

Your Details of Who is Completing the Form

Your Name *

Your Name

First Name

Last Name

Your Phone Number *

Your Email *

Your relationship to the client *

Your Organisation

Client's Details

Client's Name *

Client's Name

First Name

Last Name

Client's Phone Number *

Client's Email Address *

What documents are you requesting copies of? *

GP Letters

Session notes

Questionnaires

Whole client file

Other (Please Specify)Other (Please Specify)

Please explain the purpose of this document request: *

0 of 200 max words

Upload all relevant file request documents here, including any consent forms and cover letters.

Maximum file size: 20MB

Who will we be invoicing the File Release invoice to? *

the Client

the Parent/Legal Guardian of the Client

Lawyer

Insurer

Other

Payer Details

Payer's Name *

Payer's Name

First Name

Last Name

Payer's Phone Number *

Payer's Email *

Your relationship to the client *

Your Organisation

Who are you requesting the Client file be directly released to?

File Recipient Details (if you have not already provided these contact details earlier in this Form). If you have not already provided these details, you MUST complete this section.

Your Name

First Name

Last Name

Your Phone Number

Your Email

Your relationship to the client

Your Organisation

Due Date file copy is required by *

Consent & Acknowledgement *

I confirm that I am authorised to provide these documents and that the Client is aware of and has consented to the submission of these document/s

I understand that document review outside appointment time will incur fees

I understand that submission of this form does not guarantee same-business-day review and that document review timeframes vary.

I consent to Vitality Unleashed Psychology storing and using these documents for clinical purposes

Today's Date *

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File Release Request

Your Details of Who is Completing the Form

Client's Details

Payer Details

File Recipient Details (if you have not already provided these contact details earlier in this Form). If you have not already provided these details, you MUST complete this section.

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