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