Authorization for Release of Information

By signing this form, you are giving permission for these organizations to share information about your situation.

Your Information

NAME:
DATE OF BIRTH:
DRIVER LICENSE / ID NUMBER:

I authorize Anger Solutions of Bend, Oregon to provide information to:

Their Information

NAME:
EMAIL ADDRESS:
PHONE NUMBER:

Including records of:

Family History Domestic Violence Anger Management

Domestic Violence records include all aspects of history of violence, alcohol and drug risk factors, assessment of current risk to victim / partner and others.

I agree that the agencies and individuals listed above may share and exchange information about my family and my circumstances.

Purpose: The information received will be used to evaulate my situation and to plan for and coordinate services for me and my family.

This permission is good for one year or until: REVOKED IN WRITING

I can cancel this at any time, but I understand that the cancellation will not affect any information that was already released before the cancellation. I understand that information about my case is confidential and protected by State and Federal law. I approve of this information. I understand what this agreement means. I am signing (marking) on my own and have not been pressured to do so. FULL NAME (or other mark) symbolizing your understanding, agreement, and consent with all of the above information:
DATE:

To those receiving information under this authorization: This information disclosed to you is protected by State and Federal law. You are NOT authorized to release it to any agency or person not listed on this form without specific written consent of the person to whom it pertains unless authorized by other laws.