Consent Form for Case Study by tut53443


									Case Study Consent Form

Consent Form for Case Study
     This case study is being prepared by ___________________________________
     as a requirement for the course Graduate Diploma in Gestalt Therapy,
     that s/he is taking through Sydney Gestalt Centre.
     The purpose of this assignment is to complete a case study in the
     application of the principles of dialogical psychotherapy and methodology
     to the practice of Gestalt Therapy.
     The information from the study will be used to prepare an assignment that
     will only be read by the Director/Course Facilitator. All of the information
     you provide will be confidential and no names or other identifying material
     will be used.
     If you wish to cease your involvement in the study at any time you are free
     to leave without any penalty or prejudice to your future treatment.
     If you have inquiries regarding the conduct of the project please contact
     The Director: Philip Oldfield
     Address: 53 Smith Street, Surry Hills
     Telephone: 92110109

     I understand that the information collected will be used for the purpose
     of preparing an assignment on a case management study and I consent
     for the information to be used in that manner.
     If you agree to take part in this project please sign below:


     _________ /_________ /_________

22                             First Year Reader –   Sydney Gestalt Institute

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