Substance Abuse Treatment Release Form

Client Name: Date of Birth: Address: Name of Agency/Provider Releasing Information: Name of Person/Agency Receiving Information: Recipient Address: Information to be Released: Purpose of Disclosure: This consent will expire on (date or event): I understand that I may revoke this authorization at any time in writing to the agency listed above except to the extent that action has already been taken. Initial here to acknowledge: Client Signature: Date: Witness Signature (if required): Date: