Release of Information for Child Protective Team

Children's Advocacy Center
Serving Bastrop, Lee & Fayette Counties
Release of Information for Child Protective Team
Client's Name:
Client's Name:
Client's Name:
Client's Name:
Client's Name:
Client's Name:
I,
(Parent and/or Legal Guardian's Name)
authorize the Children's Advocacy Center (CAC) Serving Bastrop, Lee and Fayette Counties to release information to the Multidisciplinary Team associated or pertaining to the client's case regarding:
- Attendance / Participation in Therapy Services
- Advocacy
- Case / Service Coordination
I understand this release may be revoked at any time by notifying a member of CAC in writing and am aware this will affect my eligibility for services. The MDT generally includes: prosecution, law enforcement, DFPS, medical professionals, mental health professionals and other community agencies specific to the county. All MDT partners are required to follow all HIPAA and CAC confidentiality requirements.
Signature of Parent and/or Legal Guardian
Date

MonthDayYear
Signature of CAC Staff
Date

MonthDayYear
Stacey Helm, LPC-S, LSOTP, NCC
LPC-S License #62725, LSOTP License #99836
Sarah Moreno, LPC, NCC-License #80546
Franco Weaver, LPC, NCC-License #81843
Kelly Gilleland, PhD, LPC-S, LSOTP-S, NCC
LPC-S License #72661, LSOTP-S License #99469
Brittney Sartor, LMSW - License #51814
Matthew Robbins, LPC License #93233
Katie Gross, PhD, LPC-S – License # 68505
Ashley Pattillo, LPC-Associate License #95503
Supervised by Stacey Helm, LPC-S License #62725
Should be Empty: