Release of Information Form

New Haven Youth & Family Services, Inc.

Consent for Release of Information

Client Name_______________________________________________ Date of Birth ______________________   I do hereby consent to and authorize New Haven Youth & Family Services, Inc to obtain and/or release information pertaining to the person(s) and/or family noted above as indicated below:

 

_______________________________/___________________________________

Name of Person                                                         Facility / Organization

__________________________________________________________________

Street Address                                           City                          State                         Zip

­­­______________________/____________________

Phone #                                              Fax#    

The following information may be disclosed:

Obtain              Release

( x)                  ( x)              verify receipt of services received (including admission & discharge dates)

( x)                  ( x)              medical history and information including exams and immunization records

( x)                  ( x)              diagnosis (including brief description of progress and prognosis)

( x)                  ( x)              educational records including achievements, assessments, and testing results

( x)                  ( x)              psychological tests, projective assessment results, and/or treatment plans

(    )                   (    )               other ___________________________________

 

To be used for the following purposes:

  • to assist in providing on-going treatment / continuing care
  • to coordinate treatment efforts with the above mentioned family/ person
  • to coordinate educational planning with school personnel
  • to enable caseworkers, officers, and judges to support treatment goals and comply with the terms and conditions of probation and/or other court-ordered services.
  • other: ________________________________________________________________________ 

I understand that I need not consent to the release of this information in order to obtain services. I choose to do so willingly and voluntarily for the purposes specified above. This authorization will terminate 60 days from the date of discharge, unless I specify a date, condition, or event upon which it will expire sooner. Further, I understand that I may revoke this consent at any time by notifying my Program Specialist in writing except to the extent that action has been taken in reliance on my consent. Redisclosure of this information without written consent is prohibited.

______________________________________________

Signature of youth if emancipated or 18 years or older/Date

 

______________________________________________

Signature of Parent, Guardian, or Authorized Representative of the Client/Date

 

______________________________________________

Signature of NHYFS Representative or Witness/Date