ࡱ> TVS bjbjSS 2O11. . 8|~ lllll$@"$# PP^# ll8 dllmlTȓN 0~ %%%T# # ~ %. N: RELEASE OF INFORMATION AUTHORITY I .(Print full name) hereby consent to the named Authorised Clinician of the Children's Court Clinic to obtain written or verbal information regarding myself or my children, for the purpose of preparing an Assessment Report for the Childrens Court. Permission is given only for the purposes of the preparing an Assessment Report for the Childrens Court, and this authority will automatically lapse when the Report is submitted to the Court. If permission is not grant for a particular professional, the information may be obtained under Chapter 16A of the Children and Young Persons (Care and Protection) Act 1998 This section provides for the exchange of information between prescribed bodies relating to the safety, welfare or wellbeing of a particular child or young person, or class of children or young persons, to assist the recipient to make any decision, assessment or plan or to initiate or conduct any investigation, or to provide any service relating to the safety, welfare or well-being of the child or young person or class of children or young persons, or to manage any risk to the child or young person (or class of children or young persons) that might arise in the recipient agencys capacity as an employer or designated agency. Signature of person giving permissionDate.. Name of Authorised Clinician Signature of Authorised ClinicianDate..... I consent to the above named Authorised Clinician obtaining information from the following person(s), professionals and/or agency(s): Name of Family or Community MemberName of Person about whom information is being provided. (eg self or child)Relationship to YouTelephone Number or email address     Name of Professional (if known)Agency or Practice NameName of Person about whom information is being provided. (eg self or child)Telephone Number or email address         Sydney Childrens Hospitals ǿ Parramatta Childrens Court 2 George St Parramatta Locked Bag 4001 Westmead NSW 2145 DX8257 PARRAMATTA Phone: +61 2 8688 1530 Fax: +61 2 8688 1520 Email: schn-childrenscourtclinic@health.nsw.gov.au !"#=CU_dj3 4 6 J N Y ! " # $ I W [ e g ҷëÙëÊ~tleZlZlRhO{OJQJhY{5OJQJ\ hY{5\hY{OJQJhY{CJOJQJhY{CJ OJQJaJ hY{hO{CJ OJQJaJ "hO{hO{6CJ OJQJ]aJ hO{CJ OJQJaJ h*yCJ OJQJaJ hO{hO{CJ OJQJaJ hO{h~CJ OJQJaJ h~CJOJQJh~OJQJh~5CJOJQJ\!"#5 6 ! 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