Authorization for Release of Information
- CONFIDENTIAL
The Peacemaker Center
Clients Name
First Name
Middle Name
Last Name
Is Client under age 14? All legal guardians must sign a release form.
*
Yes
No
Clients Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Client's Phone Number
Client's Birth Date
-
Month
-
Day
Year
I give full authorization to release confidential client information to the following:
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
Fax Number
Email
example@example.com
Client Signature
Sign with your mouse, stylus, or finger
Clear
Parent/Guardian Name if child under age 14
Parent/Guardian Signature if child is under age 14
Sign with your mouse, stylus, or finger
Clear
Parent/Guardian Name if child under age 14
Parent/Guardian Signature if child is under age 14
Sign with your mouse, stylus, or finger
Clear
SUBMIT RELEASE
Should be Empty: