RELEASE/ACQUISITION OF INFORMATION	Date
Client	Meeting Date with Client
Staff	Meeting Date with WSC
Go over each the release with the client and his guardian at intake and when there is a need to release information either to or from a specific provider. Do NOT have the client/guardian/advocate sign until information needs to be released.
Release/Acquisition of Information

The individual client/guardian/advocate hereby authorizes the release and acquisition of specific digital/non-digital information.
Individual Client (print)

Name of Service Provider or Authorized Representative Providing/Releasing Information

Name of Service Provider or Authorized Representative Obtaining/Acquiring Information

Specific information to be released (describe)

Form in which the information is to be released (check one)
Written
Verbal
Video
Audio
Other (specify)
Purpose of the information to be released (describe)

The release of information request is authorized for thirty (30) days from the date of signature.

Individual	Signature	Date
Client
Guardian
Advocate/Family
Staff
WSC