DCF Release of Information

Consent for Release of Information and Records

Palm Beach/Circuit 15
Client Name*

First NameLast Name
Client Name 1
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Address 1
I hereby authorize
Name of Current College/University
To disclose my academic information to the following person(s) or organization(s)
for the purpose of identifying appropriate services and / or treatment needs, facilitating service delivery, and ensuring effective overall case supervision. I understand this consent is effective upon date of signature, and will not exceed one (1) year from the date of signature for ongoing service provision.
I certify that this consent is made freely, voluntarily, and without coercion. This consent remains in effect until the date of expiration, unless expressly revoked to ChildNet or termination of case supervision of the child(ren), whichever occurs sooner. Any information released prior to the revocation of this consent shall not be a breach of confidentiality. I also understand that if the individual or organization receiving the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these federal regulations. I authorize a photocopy or a scanned copy of this consent is as effective as the original.
Client Name 2
Signature of Parent / Legal Guardian*

Clear
Date

MonthDayYear
Date
Form Name
Should be Empty:

Consent for Release of Information and Records