CONSENT TO RELEASE CONFIDENTIAL INFORMATION

CONSENT TO RELEASE CONFIDENTIAL INFORMATION
I allow HPWC to notify the victim and/or the victim’s community and/ or legal advocates that I have been accepted or rejected into treatment.
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I allow HPWC to notify the victim with periodic reports about my participation in the program.
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I allow HPWC access to information held by all prior and concurrent treatment agencies, including Domestic Violence Perpetrator Programs, mental health agencies, and drug and alcohol treatment programs.
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I allow HPWC to provide relevant information regarding my participation to the following entities:
Victim(s):
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Significant Others:
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Courts:
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Parole Officer:
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Probation Officer:
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Child Protective Services:
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Child Welfare Services:
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Other DSHS Services:
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Court-appointed Guardians ad litem:
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DSHS Certifying Authorities:
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Former Treatment Facilities:
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I allow HPWC to notify any person(s) whose safety appears to be at risk due to my potential for violence and lethality. This includes, but is not limited to:
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(A) The Vitim
(B)   Any children
(C)   Significant others
(D) The victim’s community and legal advocates; or
(E)   The police
Signature*

Clear
Date*

MonthDayYear
Date
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I allow HPWC to provide relevant information regarding my participation to the following entities: