DV Victim Release of Information

Authorization to Release and Exchange Information
Name*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
I authorize and consent to communication between the National Institute for Change and the treatment victim advocate assigned to my case. The information released shall include any and all regarding attendance, compliance/non compliance with treatment, progress, attitude, safety issues (including but not limited to sobriety), and discharge summary. You further authorize this advocate to contact the identified victim to relay the same information.
1) Name of other person involved in the offense that is the named victim in this case AND their last known phone number is: (THIS IS NOT YOUR NAME AND IS REQUIRED FOR PROGRAM ENROLLMENT)*
Named Victim's Phone Number*

Area CodePhone Number
The last known phone number for the person from question 1. THIS IS REQUIRED FOR PROGRAM ENROLLMENT, EVEN IF IT IS NO LONGER VALID.* Area Code Phone Number
Optional: I consent to having my information released to the DVOMB for research and statistical purposes. This is optional and has no bearing on program enrollment.
Signature of Client:*

Clear
Date:*

MonthDayYear
Date
Signature of Therapist:

Clear
Should be Empty:

Authorization to Release and Exchange Information