SARC Consent to Referral and
Release of Information for Counseling

SARC partners with Empowered Connections, a counseling agency, to provide up to six (6) therapy sessions at no cost to the client for individuals in need of short-term mental health support. These sessions are provided by licensed clinicians and are funded through specific grants. As part of this partnership, SARC and Empowered Connections work together to ensure safety, continuity of care, and effective treatment planning.

Consent to Referral & Release of Information

By signing this form, I authorize SARC and Empowered Connections to exchange the following information for the purposes of referral, treatment coordination, outcome tracking, and safety monitoring:

• My contact information and scheduling availability
• Reason for referral and relevant psychosocial history
• Session attendance, cancellations, and engagement
• Notification if any of the following occur:
  Suicidal ideation or suicide attempt
  Threats of harm to others
  Psychiatric hospitalization
  Disclosure of child abuse or neglect
  Ongoing abuse or imminent danger
• Progress toward treatment goals and discharge status
• Outcome measurement data required for grant compliance

This information may be shared via phone, email, secure fax, or in person. I understand that all counseling records will be maintained by Empowered Connections, LLC, in accordance with HIPAA, state, and federal privacy laws. SARC will not have access to clinical notes or full records.

This release is valid for one (1) year from the date signed and may be revoked by me in writing at any time. I understand that my participation is voluntary and I have the right to decline signing this form; however, without a signed Release of Information, I will not be eligible to receive services through Empowered Connections. Other service options may be discussed with me as appropriate.

Client Acknowledgment and Program Requirements

By signing below, I acknowledge and understand the following:

1. I am being referred to Empowered Connections for up to six (6) therapy sessions at no

2. All sessions are provided by licensed clinicians.

3. Before beginning services, I will meet with a SARC employee, to determine whether Empowered Connections is an appropriate fit for my needs.

4. If I am not determined to be appropriate for this referral, SARC will provide alternative resources or referrals to support my mental health care.

5. I must be actively enrolled with a SARC program while receiving Empowered Connections services.

6. A SARC employee will check in with me at least once every 30 days to support care coordination and determine next steps.

7. Empowered Connections will share progress updates, including how many sessions I attend and when I am discharged.

8. I understand that if I need to cancel a session, I must notify my Empowered Connections counselor at least 24 hours in advance. Missed sessions without notice will be counted as no-call, no-shows.

9. If I miss two (2) scheduled sessions without cancelling 24 hours in advance, I will no longer be eligible for continued services through Empowered Connections.

10. I understand that additional sessions beyond the initial six must be pre-approved by SARC and are not guaranteed, as this referral program is time-limited and may end after September 2025. Extensions will be considered only in rare circumstances.

11. I am responsible for ensuring I have a safe and private space to participate in therapy sessions, which are primarily held virtually.

12. If I experience a crisis between sessions, I can call the SARC 24/7 Helpline at 410-836- 8430 or dial 911 in an emergency.

13. Sessions not used by September 30th 2025 will be considered expired and no longer be available for your use. 

If you are interested in your child receiving counseling through Empowered Connections, please include their full name and date of birth below.

By signing this form, you acknowledge and agree to the following:

I authorize SARC to release relevant information and submit a referral to Empowered Connections for the purpose of initiating counseling services for my minor child.

*** According to Maryland Health-General Code § “A minor 16 years old or older can consent to treatment of a mental or emotional disorder by a physician or psychologist, but cannot refuse such treatment when a parent or guardian has given consent.”