Domestic Violence Shelter Information Release
Client Information
Client Name
Date of Birth
Address
Phone
Date
I authorize the release of the following information:
Basic Identification Information
Case Records
Other (specify below)
To/From (Agency or Person receiving/releasing information)
Purpose of Disclosure
This release will expire on
Client Rights
I understand I can revoke this authorization at any time in writing.
I understand signing this form is voluntary and will not affect my access to services.
Client Signature
Date
Witness Signature
Date