I, the undersigned client, hereby acknowledge that I have been informed about and understand the referral to the third party named above. I consent to the sharing of relevant information about my case with this third party for the purpose of [briefly describe purpose, e.g., "providing specialized services" or "collaborative support"].
I confirm that:
1. I understand the nature of the referral and the implications of sharing my information with the third party.
2. I have had the opportunity to ask questions and have received satisfactory answers regarding this referral.
3. I am aware that I can withdraw my consent at any time by notifying my service provider in writing.
4. My personal information will be handled in accordance with applicable privacy laws and the service provider's privacy policy.
