Military Consent To Release

CONSENT TO DISCLOSE PERSONAL HEALTH INFORMATION

(PURSUANT TO THE PERSONAL HEALTH INFORMATION PROTECTION ACT 2004)

I hereby authorize Moss Psychology to exchange my personal mental health information with the Mental Health Unit at 8 Wing Trenton for the following purposes: Mental health evaluation, treatment and/or care and treatment planning.

The information to be disclosed may include mental health evaluations, including developmental, educational, alcohol/substance use, forensic, and social history, clinical session notes and progress reports.

I have had the opportunity to discuss this consent and fully understand this request/authorization to release records and information, including the nature of the records and their contents. This request is entirely voluntary on my part. I understand that I may take back this consent at any time, except to the extent that action based on this consent has already been taken. This consent will expire automatically after one year from the date on which it is signed, or upon fulfillment of the purposes stated above.

If you have any questions or concerns regarding the consequences and implications of releasing any aspect of your personal health information to the Canadian Military, these should be directed to the Mental Health Unit at 8 Wing Trenton.