Informed Consent

By signing this Informed Consent to Release/Receive Information form you are giving legal permission for TRI staff to obtain/reveal information when contacting another organization/individual while we work with you.

If you have questions, ask your TRI Advocate or front desk staff to explain how to fill this out correctly.

Do NOT submit a TRI consent form if you have not previously submitted an Intake Packet.

If you are currently working with another agency, have that agency fax over their consent form, with their letterhead, signed by you.

Again, if you have not completed a TRI Intake to become a Consumer of TRI, do not sign this form yet.

If you are a current Consumer of TRI and aged 18 or older, click the CONTINUE button below.

82 Washington Street, Poughkeepsie, N.Y. 12601
INFORMED CONSENT TO RELEASE /RECEIVE INFORMATION

for CONSUMERS aged 18+
Your Name (CONSUMER Name)*

First NameMiddle InitialLast Name
CONSUMER Address*

Street Address

Street Address Line 2

CityState

Zip Code
CONSUMER Date of Birth*

MonthDayYear
Social Security number:
* Social Security Number and D.O.B. are required for governmental agencies which includes the Social Security Administration.

Note: For persons receiving treatment for alcohol or drug abuse, any information disclosed as per this release is protected by Federal Law. Federal Regulations (42CFR Part 2) prohibit any re-release or further disclosure of information without the specific written consent of the person to whom it pertains or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is not sufficient for this purpose. Rev. July 2013
I hereby give permission (you can choose both)*

to release information to and/orto receive information from:
A Specific Person's name or type "Any Authorized Personnel"
Who do you want to give TRI staff permission to discuss your services with?
Their Title
Who is the person to you? Examples: Case Manager/ Parent/ Spouse etc...
The Agency the Person works for
Only if the Person is from an Agency. Otherwise leave blank
Address
The physical/ mailing address of the Person.
Requested Information:
Example: "Any necessary information pertaining to the above consumer regarding services"
Information needed for:
Why do you need your TRI Advocate to speak with this person? Examples: Housing/ Benefits Advisement/ Assistance with effective communication etc...
My consent is subject to revocation at any time and expires: Earlier than*

30 days60 days90 days6 months1 year
Date

MonthDayYear
Date
Consumer's Signature*

Clear
Witness Signature Date

MonthDayYear
Date
Witness' Signature

Clear
Should be Empty:

82 Washington Street, Poughkeepsie, N.Y. 12601

INFORMED CONSENT TO RELEASE /RECEIVE INFORMATION