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.