National Network to End Domestic Violence Official Website

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This form is used to help a client assess risks and benefits of having an agency release some of her or his confidential information to another individual or/and agency. The form enables the client to choose what information an agency may share, how it is shared, with whom, and for how long.

Your agency or/and partners in a collaborative community response are encouraged to adapt and use this model release of information form.

Instructions to adapt this template for use:

  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).

Download adaptable template form:

 

Distribution Permissions: This piece may be reproduced or adapted for nonprofit or educational uses with acknowledgement of authors and/or publisher. This form was created by Julie Field, founder of The Confidentiality Institute and the Safety Net Project, National Network of Domestic Violence. (2008, last revised 2010).