Substance Abuse Treatment Information Consent Form

Client Information

Client Name Date of Birth

I authorize the release and exchange of information regarding my substance abuse treatment as described below.

Recipient of Information Purpose of Disclosure Description of Information to be Disclosed Expiration Date or Event

I understand that I may revoke this consent at any time in writing.
I understand that a revocation will not affect disclosures already made.
I understand that my substance use records are protected under federal law (42 CFR Part 2) and cannot be disclosed without my written consent unless otherwise permitted by law.

Client Signature

Date

Parent/Guardian/Representative (if applicable)

Date