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

I hereby authorize ___________________________________________________________________ who has provided services to me,

(Name)

to furnish Life's New Beginnings, Inc., or its representative, the following information:

________________________________________________________________________________

________________________________________________________________________________

The form in which the information is to be released is (check one):

written

verbal

video

The form in which the information is to be released is for the purpose of:

________________________________________________________________________________

________________________________________________________________________________

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

Release of Information

I hereby authorize Life's New Beginnings, Inc., to release information to the following authorized person or agency herein specified:

________________________________________________________________________________

The specific information to be released is: ______________________________________________

The form in which the information is to be released is:

written

verbal

video

The form in which the information is to be released is for the purpose of:

________________________________________________________________________________

________________________________________________________________________________

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

Individual	Signature	Date
Client
Guardian
Staff
WSC