The Bear Haven Authority to Obtain &/or Release Information I, * First Name Last Name of Address 1 Address 2 City State/Province Zip/Postal Code Country Authorise The Bear Haven to exchange information with other relevant professionals or organisations. This authority permits discussion between The Bear Haven and the parties mentioned below in addition to the exchange of written reports. This contact with other parties would be discussed with you prior, except in an emergency or if your safety and well-being are at risk. I understand that I can change or cancel this authority at any time and can refuse to permit information exchange, except in the case of an emergency. I understand that parties mentioned below will be provided with a copy of this authority before providing The Bear Haven with information. I am being supported by, please list the names below: (e.g. G.P, Case Worker, Psychologist). Support Provider Name First Name Last Name Phone (###) ### #### Support Provider Name First Name Last Name Phone (###) ### #### Support Provider Name First Name Last Name Phone (###) ### #### Date MM DD YYYY I authorise the above. YES Thank you!