Sample Release Forms
Release of Domestic Violence Information
Insert Agency Name
Address
Telephone Number, Fax Number
Client:__________________________________________
Children in Client's Custody:
_______________________ _______________________ __________________
_______________________ _______________________ __________________
I, _________________________, hereby give permission to (Insert Agency Name) staff to release and/or obtain domestic violence information from:
__________ County D.S.S _____________ Hospital
__________ County C.P.S. _____________ Police Department
__________ County M.H.S. Attorney ______________________
Other: State/Local Health Department
Other: _____________________________________________________ regarding myself and/or the children listed above. I understand that the information will be used only to help make decisions related to my health and safety.
Client signature: _______________________________ Date:______________
Witness signature: ______________________________ Date:_______________
Note: Witness optional.
Unless otherwise specified, this authorization will expire one year from date signed.
Exchange of Domestic Violence and HIV-Related Information
Insert Agency Name
Address
Telephone Number, Fax Number
Client:__________________________________________
Children in Client's Custody:
_______________________ _______________________ __________________
_______________________ _______________________ __________________
I, _________________________, hereby give permission to (Insert Agency Name)staff to release and/or obtain domestic violence information, including HIV-related information, from:
__________ County D.S.S _____________ Hospital
__________ County C.P.S. _____________ Police Department
__________ County M.H.S. Attorney ______________________
Other: State/Local Health Department HIV Partner Notification Program
Other: _____________________________________________________ regarding myself and/or the children listed above. I understand that the information will be used only to help make decisions about whether partner notification should proceed and to obtain referrals for domestic violence services.
Client signature: _______________________________ Date:______________
Witness signature: ______________________________ Date:_______________
Note: Witness optional.
Unless otherwise specified, this authorization will expire one year from date signed.
