Waiver of Confidentiality

By submitting your name and EMail address in this form you are agreeing to allow communication regarding the listed client between Brian Esty and the listed practitioner. This may be another therapist, teacher, educational institute or family member. Please submit one form for every client / practitioner relationship you would like for me to freely consult with.

You may select whether you would like only verbal discussion, or additionally written communications and session videos to be forwarded. This form is required for both my records and the participating practitioner, before I can discuss any therapeutic issues outside of the client / therapist relationship.


Your Name (required)

Your Email (required)

Client-You or Your Child's Name (required)

Practitioner / Institute Name (required):

Practitioner / Institute Email (Optional)

I agree to permit verbal discussion between the listed parties regarding the listed client / child:

I agree to permit written discussion between the listed parties regarding the listed client / child:

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