Consent for Disclosure and Release of Information
This form is to be completed when there is a request of client information made by a party other than  SOAR or its funding source.
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Email *
Today's Date:
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Legal Guardian/Parent First Name *
Legal Guardian/Parent Last Name *
Child's First Name *
Child's Last Name *
Child's Date of Birth
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Information may be released regarding (check all that apply): *
Required
Information may be released to the following party(ies)
Information may be received from the following party(ies):
DESCRIPTION OF INFORMATION THAT MAY BE DISCLOSED OR RELEASED: *
Required
Purpose: The purpose of this disclosure of information is to coordinate treatment services, share  information relevant to service delivery and to improve our assessment and service delivery, and/or if  other purpose, please specify:
Revocation and Expiration
Revocation: I understand that I have a right to revoke this authorization, in writing, at any time by  sending written notification to the Executive Director of SOAR. Revocation will become effective on the  date of notification and will not apply to information that has already been released or obtained in  response to this authorization.

Expiration: Unless sooner revoked, this consent expires one year from the date of original submission
Condition: I further understand that SOAR will not condition my service delivery on whether I give  authorization for the requested disclosure. However, it has been explained to me that failure to sign this  authorization may have the following consequence:
Re-Disclosure
Federal law prohibits the person or organization to who disclosure is made from making  any further disclosure of this information unless further disclosure is expressly permitted by the written  authorization of the person to who it pertains I understand that I have the right to inspect and obtain a copy of the information to be disclosed.

I may also receive a copy of this authorization for my records.
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