National Network to End Domestic Violence Official Website

escape this website SAFETY ALERT: If you are in danger, please use a safer computer, or call 911, a local hotline, or the U.S. National Domestic Violence Hotline at 1-800-799-7233 and TTY 1-800-787-3224. Learn more technology safety tips. There is always a computer trail, but you can leave this site quickly.

The National Network to End Domestic Violence. Click to return to the home page.

Text Size:

Action Alerts

Sign up for action alerts...

No More
WomensLaw

Content

 Print  Email

Client Limited Release of Information Form

 

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).