This Consent to Release Information supports the referral process.
You must also submit the Local Care Team Referral Form.

Consent to Release Information

Montgomery County Collaboration Council

TO FAMILIES: 
We can help you better if we are able to work with other agencies that may know your child and family. By signing this form, you are giving permission to the Collaboration Council to share information about your child. You will not be denied services for which you are eligible if you choose not to sign this form.

I understand that the purpose of this authorization is to allow agencies to share information and records in order to plan and provide services to the above child in a coordinated and effective way. I agree that the agencies listed below may share and exchange information about my child. I understand that information exchanged under this authorization is confidential. I understand that this authorization expires automatically one year after signing unless otherwise stated below, but may be revoked by me in writing at any time except to the extent that information has already been released with this authorization.

authorize the release of information and records on the above child by the following public agencies. 

Purpose of Request:

For Local Care Team (LCT) to plan for appropriate services in order to maintain child/youth in the least restrictive environment.