Employment Assistance Social Services Release

Client Name Date of Birth Case Number

Authorization

I hereby authorize the release and/or exchange of information between the social services agency and the following individual(s) or organization(s) for the purpose of providing employment assistance services:

Organization(s) or Individual(s) to Receive Information Type of Information to be Released

Purpose of Release

Client Rights

• I understand that my records are protected under applicable privacy laws and regulations.
• I may revoke this authorization at any time by submitting a written request to the agency.
• This authorization will expire upon the following date/event/condition: