SOMERSETIS Yours cost

SOMERSET COUNTY LOCAL CARE TEAM

RELEASE OF INFORMATION FORM
Authorization to Release and Exchange Confidential Information
Youth's Name
Youth's Date of Birth

MonthDayYear
Date
I authorize the release and exchange of information between all members of the Local Care Team, to include: the Somerset County Local Management Board, Inc., Department of Juvenile Services, Developmental Disabilities Administration, Somerset County Public Schools, Health Department, Department of Social Services, Core Service Agency, and the Division of Rehabilitation Services.

The information may include, but is not limited to:
- Involvement with community agencies and organizations
- Progress in treatment and or placement
- Attendance and compliance with programs
- Diagnostic Information
- Dates of admission and discharge
- Treatment plans
- Discharge summary
- Recommendations
- Urinalysis results
Please specify if any limitations to the exchange and release of information
The purpose of the disclosure authorized herein is to facilitate: (Please check those applicable)

Assistance with identification of individual needs and potential resources to meet identified needs for a family with an intensive needs childInteragency discussion and problem solving for individual child and family needs and systemic needsVoluntary Placement Agreement (VPA) Discussion
Signature of Parent/Guardian

Clear
Date

MonthDayYear
Date
It is understood that this authorization expires one year from the date signed.
Date

MonthDayYear
Date
Signature of Witness:

Clear
Date

MonthDayYear
Date
Should be Empty:

SOMERSET COUNTY LOCAL CARE TEAM

It is understood that this authorization expires one year from the date signed.