Safe Children Coalition Release of Information

General Information

This form will take approximately 10 minutes to complete.

Name of Chosen Specialist assigned to your family through Safe Children Coalition:(Required)

Please enter the name of your Chosen Care specialist.

Name:(Required)

Your First Name Your Last Name

Email:(Required)

Your personal email.

Phone:

Your cell phone.

Information Release

Please fill in the appropriate information for the person/organization you are allowing us to speak with. Please be as detailed and specific as possible.

Organization/Individuals Name:(Required)

Please name the organization we are allowed to speak with. This would be the name of your foster care organization, church, counselor, CPS, etc..

Email(Required)

Phone(Required)

Organization/Individuals Address:

Street Address City State / Province / Region ZIP / Postal Code Country

Information to include the following:

Please specify what we are allowed to talk to this person or agency about. A sample answer is: “Details related to the services I am receiving and parent coaching progress notes.” You can also be very general, for example: “Anything I have shared with my Care Manager.” You can be very specific as well, for example: “You may confirm that I am engaged in services with Chosen.”

This protected health information is being used for the following purposes:(Required)

Please explain why we are communicating with this person or organization. This can be very brief, such as “The information is being used to keep my case worker informed about my parent coaching sessions with Chosen.”

Signature(Required)

Date(Required)

Client Payment

Registered 501(c)(3). EIN: 81-2872095

Safe Children Coalition Release of Information

General Information

Information Release

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