The following is an authorization for exchange of information for the family of:

I/We, the undersigned, hereby authorize the following agencies and their officers and employees to discuss any medical, social, educational, and psychological information concerning the above-named family members with any other agencies listed below. I/We, the undersigned, acknowledge that the information that will be shared by any of the agencies listed below may be confidential and privileged, and I/We hereby expressly waive that confidentiality and privilege for any information shared by any of the agencies and officers and employees listed below. This exchange of information will only be used to help coordinate referral, assessment and related helpful actions for my family and myself

Using your INITIALS, indicate which agencies you authorize to exchange information:

The consent becomes effective    and may be revoked in writing by the undersigned at any time. Date except to the extent that action has already been taken. My written revocation of this consent form will be effective upon receiving the written revocation. This consent shall expire on    or in two years. Date from the effective date, whichever is soonest. I understand that I can receive a copy of the authorization. A photocopy of this consent is as valid as the original. If I choose not to sign this consent, I will be referred to appropriate services and shall not be denied services.

Client, Parent or Guardian Name Signature

Client, Parent or Guardian Name Signature

Witness Name Signature