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 order or valid subpoena.

Parent Release of Information:  For the purpose of providing coordination of client resources and services, I as the legal guardian and/or custodial parent of above-named child, authorize Los Alamos JJAB to release and obtain information between the Los Alamos JJAB employees and the following person(s):

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

Information being requested may be released verbally and in writing.

This authorization will expire at the time my case is closed unless I have specified, in writing, another date or event that will trigger expiration. This authorization may be revoked at any time by submitting a written request to Los Alamos JJAB at P.O. Box 4716, White Rock, NM  87547 or at info@losalamosjjab.com.

I hereby certify that this request has been made voluntarily.