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Consent to Share Information

This Consent to Share Form enables a client to give signed consent for Empower You Plan Management (EYPM) to discuss personal and plan information over the phone or via email with additional parties such as Secondary Contacts (your parent, a co-parent/guardians, grandparents, close friends etc), Support Coordinators or others.
Consent to Share Information Form

Only you (EYPM) Client), your Guardian or Authorised Representative may give consent to share.

This consent is for:

A Single person can be: Family, Friend, Support Coordinator etc Organisation: will provide consent to all staff at the organisation

Organisation Type

I declare that I have the authority to approve this consent to share form in the following capacity as:

Select an option

Thanks for submitting!

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