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Sample Release Forms

Release of Domestic Violence Information

Insert Agency Name

Address

Telephone Number, Fax Number

Client:__________________________________________

Children in Client's Custody:

_______________________ _______________________ __________________

_______________________ _______________________ __________________

I, _________________________, hereby give permission to (Insert Agency Name) staff to release and/or obtain domestic violence information from:

__________ County D.S.S _____________ Hospital

__________ County C.P.S. _____________ Police Department

__________ County M.H.S. Attorney ______________________

Other: State/Local Health Department

Other: _____________________________________________________ regarding myself and/or the children listed above. I understand that the information will be used only to help make decisions related to my health and safety.

Client signature: _______________________________ Date:______________

Witness signature: ______________________________ Date:_______________

Note: Witness optional.

Unless otherwise specified, this authorization will expire one year from date signed.

Exchange of Domestic Violence and HIV-Related Information

Insert Agency Name

Address

Telephone Number, Fax Number

Client:__________________________________________

Children in Client's Custody:

_______________________ _______________________ __________________

_______________________ _______________________ __________________

I, _________________________, hereby give permission to (Insert Agency Name)staff to release and/or obtain domestic violence information, including HIV-related information, from:

__________ County D.S.S _____________ Hospital

__________ County C.P.S. _____________ Police Department

__________ County M.H.S. Attorney ______________________

Other: State/Local Health Department HIV Partner Notification Program

Other: _____________________________________________________ regarding myself and/or the children listed above. I understand that the information will be used only to help make decisions about whether partner notification should proceed and to obtain referrals for domestic violence services.

Client signature: _______________________________ Date:______________

Witness signature: ______________________________ Date:_______________

Note: Witness optional.

Unless otherwise specified, this authorization will expire one year from date signed.