Hereby give my/our permission for the free exchange of information, including Confidential reports and verbal consultation regarding myself/us/my child:

    Between:
    Introspect Psychology Group
    60 Sydney Parade
    Geelong VIC 3220
    (03) 5221 1169

    On the understanding that all information will remain confidential.

    By completing and submitting this form electronically, I am giving my consent for the above exchange of information.