If youth does not reside with legal guardian, provide the name and phone number for current placement:

Section A: Consent to Services

I authorize the complete release of my records. By signing this form, I consent to receive the following services from Street Grace: comprehensive assessment; care coordination; and follow-up services after discharge. I understand that by signing this form that I am consenting for the youth identified above to participate in Street Grace’s treatment services.

Section B: Use and Disclosure of Information

By signing this form, I authorize the disclosure of my individually identifiable information. Information that may be used or disclosed based on this authorization is as follows:

I authorize the release of my complete records including:

• Information pertaining to the identity, diagnosis, prognosis or treatment for alcohol or drug abuse, mental health disorders, educational issues/needs, legal issues/needs and/or social/recreational issues/needs.
• Information concerning the testing for HIV (Human Immune Virus) and /or treatment for AIDS (Acquired Immune Deficiency Syndrome) and any related conditions.
• Privileged communications between a psychiatrist, psychologist, licensed marriage & family counselor, or licensed professional counselor or between them concerning communications with them.
• All education information; including education records created or received by the school system. This information may include, if applicable: report cards, attendance, discipline, IEP, 504 plan, evaluations.

I authorize the disclosure of my complete records and identifiable information by the following and to the following parties: Department of Juvenile Justice, Department of Family and Children Services, Educational Provider, Juvenile Court, District Attorney’s Office, Law Enforcement, Mental Health Providers, Medical Providers, and any other providers as deemed necessary.

I authorize for Street Grace to take a photograph of the above mentioned youth, to be shared by the following and to the following parties: Department of Juvenile Justice, Department of Family and Children Services, Educational Provider, Juvenile Court, District Attorney’s Office, Law Enforcement, Mental Health Providers, Medical Providers, National Center for Missing and Exploited Children (NCMEC) and any other providers as deemed necessary.

Section C: Purpose of Use or Disclosure

The purpose of this disclosure is for Assessment Program services, Care Coordination Program services, possible completion of Victim’s Compensation application, and possible completion of a NCMEC application and other needed uses.

Section D: Expiration

Consent for Release of Information expires 24 months from the date it was signed. Consent for Information must last no longer than reasonably necessary to serve the purpose for which consent is given (42 CFR 2.31 (a) (9)).

1. I understand that Street Grace cannot guarantee that the recipient will not disclose this information to a third party. The recipient may not be subject to federal laws governing privacy of health information. However, if the disclosure consists of treatment information about a youth in an alcohol or drug abuse program, the recipient is prohibited under federal law from making any further disclosure of such information unless further disclosure is expressly permitted by written consent of the consumer or as otherwise permitted by federal law governing confidentiality of alcohol and drug abuse patient records (42 CFR, Part 2).
3. I understand that I may refuse to sign this Authorization and that my refusal to sign may affect my ability to obtain services through Street Grace.
4. I understand that I may revoke this authorization in writing at any time, except that the revocation will not have any effect on any action taken by Street Grace in reliance on this authorization before written notice of revocation is received.
5. I understand that educational records are confidential under state and federal law and by signing this Unified Release of Information; I am authorizing the release of educational records.
6. I understand that the data collected from the assessment measures may be used for agency program evaluation efforts. All data shared or published is de-identified to maintain client confidentiality.