I, , authorize
to disclose

my personal health information consisting of: case file or

the personal health information of: *
      ( * Name of person for whom you are substitute decision maker )
      consisting of: case file

to: David Howard, M.A., C.Psych., Psychologist

I understand the purpose for disclosing this personal health information to the person noted above. I understand that I can refuse to sign this consent form.