Information of Person served
Information of family/guardian (if applicable)
Abilities of Person Served
By signing below, I consent The Charles Lea Center may use the information provided on thisform and communicate with other members of my circle of support team in order to reach mydesired outcome. I consent to the release of any pertinent documentation regarding mysupport needs, diagnoses, and level of care. This information will be used by The Charles LeaCenter to make recommendations for services and possibly the use of technology to reachdesired outcomes. It does not guarantee that desired outcomes will be met.
**This consent is valid for 1 year from the date signed**