PERMISSION TO DISCLOSE HEALTH RELATED INFORMATION Name * First Name Last Name Email * Full name of practitioner who is releasing health-related information * I give permission for this practitioner of Noetic Psychology to disclose information about my psychological consultations with the following individual and/or organisations: * Please include full name and clinic details if applicable Consent: By ticking this box, I verify that the statements made in this form are correct. * I consent Thank you for submitting this form.
