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EmpowerHer Resource Center Client Authorized Representative Form
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Authorization to Advocate and Obtain Services
I, the undersigned, authorize Breaking Free Ministry, Inc., and its staff or volunteers, to assist me in applying for and accessing services necessary for my health, safety, and well-being. This may include, but is not limited to: (check all that apply)

Medicaid or other healthcare benefitsSNAP (food assistance) or other public benefitsLegal aid or representation referralsMental health or substance abuse counselingHousing and shelter assistanceEmployment, education, and vocational servicesAny other necessary service to support my transition and stability
I understand that this authorization allows Breaking Free Ministry to speak with agencies, caseworkers, legal professionals, and service providers on my behalf for the sole purpose of obtaining or coordinating services that benefit me.

This authorization is voluntary and may be revoked at any time by providing written notice to Breaking Free Ministry. Unless revoked earlier, this authorization will remain in effect for 12 months from the date of signature.
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EmpowerHer Resource Center Client Authorized Representative Form