ROI electronic

Client Name*
Who are you giving OMNI staff permission to talk to? Please write the full name and business they work at. Ex: Wheeling High School, Dr. Bruce Banner, etc.*
What town/city is the person or business located? *
What is the phone number for the person or business?*
Do you give consent for a full release (all information) or do you wish to select only specific information to be released?*

Everything (full release)Specific information to be released
Select all that apply below:

Alcohol and Drug HistoryAlcohol and Drug Treatment Goals & ProgressAssessment, Diagnosis, and RecommendationsDischarge/Transfer SummaryDrug Screen ResultsEducational Attendance, Behavior, TestingMedical Diagnosis, Treatment, Medication ManagementPsychiatric EvaluationPsychological EvaluationSocial Emotional DevelopmentTreatment Plan or SummaryTreatment Update Progress or ParticipationOther
Other:
I understand that the sharing of information may assist in providing high quality services by: improving assessment and treatment planning, sharing information relevant to treatment, and when appropriate, coordinating treatment services.

I understand that I have a right to revoke this authorization, in writing, at any time by sending written notification to OMNI Youth Services, Attn: Doryce McCarthy. I further understand that revocation of the authorization is not effective to the extent that action has been taken in reliance on the authorization prior to revocation.

Unless revoked sooner, this consent becomes effective upon the date signed and expires no later than six months from the below date:
MonthDayYear
Date
Unless I have specially requested in writing that the disclosure be made in a certain format (e.g. in person, in writing, by phone), OMNI Youth Services reserves the right to disclose the information as permitted by this authorization in any manner deemed appropriate and consistent with applicable laws and best practices, including electronically.

I understand that OMNI Youth Services will not condition the services received on whether full authorization for the requested disclosure is authorized. I understand that I have the right to inspect and copy the information to be disclosed. I further understand that refusal to authorize the release of information specified above will prevent disclosure of such information to the organization/person identified above, which may result in not receiving the highest quality services.
Client Signature (if 12 years old or older)

Clear
Parent /Guardian Signature (if applicable)

Clear
Parent/Guardian Name (if applicable)
Witness

Clear
Name of the person that sent you this form *
Should be Empty: