All information will remain confidential according to the JJAB Privacy Policy unless I have authorized its exchange below, except in the following circumstances: danger of harm to self or others, suspected child or vulnerable-adult abuse or neglect, or court subpoena.

Parent Release of Information: For the purpose of coordination of client resources and services, as the legal guardian and/or custodial parent of above named child, authorize JJAB Resource Specialist to release and to obtain information from regarding said minor child between the Los Alamos JJAB Resource Specialist and the following person(s):

Client Release of Information (if age 18): For the purpose of coordination of client resources and services, I authorize JJAB Resource Specialist to release and to obtain information from the following person(s):

Information being requested may be released verbally and in writing. This authorization may be revoked at any time by submitting a written request to the LA JJAB Resource Program at P.O. Box 4716, White Rock, NM 87547 or at referral@losalaomsjjab.com. I hereby certify that this request has been made voluntarily.

I hereby certify that I have explained to the client identified above the purpose of this disclosure of information and the purpose for obtaining the requested information. I understand and have explained to said client that the information obtained is to be maintained strictly confidential and cannot be re-disclosed to any third party without the expressed written consent of the client or as stated within the JJAB Privacy Policy.

JJAB Resource Specialist: __________________________________ Date ____________