Consent for Disclosure of Information 
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Every client entering the BIPP program is required to sign a “Consent of Release of Information” to the referral sources. I understand that Higher Hopes Counseling BIPP will contact my referring agent. Disclosure is limited to information regarding attendance, participation, information exchange, coordination of services and referrals. 
I hereby authorize Higher Hopes Counseling to disclose records to the following agencies for (type your name below)
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TDCJ-CJAD (Mandatory for the purpose of performing program assessment and other research

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Probation / Parole

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County Courts of Law

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Your Attorney

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TDPRS (Texas Department of Protection & Regulatory Services)  

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County DA Office

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I understand that I may revoke this consent at any time and that my request for revocation must be in writing. If not earlier revoked, this consent for disclosure of information shall expire 30 days after my completion of or termination from Higher Hopes Battering Intervention and Prevention Program.

I understand my right to confidentiality.  I further understand that this consent form gives Higher Hopes permission to share confidential information about me in the way described above.

Client Name

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Date

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