National Network to End Domestic Violence Official Website

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This form may be used by agencies to provide upfront notice to each client (e.g. victim, survivor) about their rights and your practices. This includes your agency's information sharing and confidentiality protections and requirements, and, the client's rights regarding the confidentiality of their personal information and communications.

Instructions: Your agency and/or collaborative community response partners are permitted to adapt and use this model form in your work. To adapt this template for use, simply:

  1. add information relevant to your specific agency, partnership and funders;
  2. insert your [program/agency/partnership/collaboration names] and letterhead;
  3. remove any generic template blue instruction notes and other notices from us;
  4. if needed, minorly change certain words like victim to match the language your agency or partnership prefers (e.g. client, victim, survivor, service participant).
  5. add any additional rights that the client has and any additional obligations that your agency has.

Forms to download and minorly adapt for use:

This template form was created by The Confidentiality Institute in partnership with the Safety Net Project at the National Network to End Domestic Violence in 2008.