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Client Consent to Disclose Personal Information

Statement of Use

Personal information that is collected will be used only for the purpose of providing and coordinating the provision of essential services. Services will be delivered by the service providers listed on this form. Where services need to be delivered by extended service providers, information will only be disclosed to them with explicit consent. Information will not be used for any other purpose, unless required by law, and will only be disclosed to additional parties with the consent of the individual to whom it pertains. 

Consent

First Name

Last Name

Date of Birth

List of all accompanying family members:

Consent

I hereby authorize...

I hereby authorize...

to use and disclose my personal information from my client file to and between the service providers as specified below:

to use and disclose my personal information from my client file to and between the service providers as specified below:

I understand the reasons for the sharing and use of the information as described above, that my consent is voluntary, that I can at anytime withdraw my consent by written notice without any penalty and without jeopardy to any future services, and that failure to provide consent will not result in any adverse decision about my rights, benefits or services, other than limiting the ability of the organizations to work together on my behalf.

Date Effective:

Client's Full Name

Client's Signature

Signature