VOICES AGAINST VIOLENCE/LAURIE'S HOUSE

VOICES AGAINST VIOLENCE/LAURIE'S HOUSE
READ FIRST: Before you decide whether or not to let Voices Against Violence share some of your confidential information with another agency or person, an advocate at Voices will discuss with you all alternatives and any potential risks and benefits that could result from sharing your confidential information. If you decide you want Voices to release some of your confidential information, you can use this form to choose what is shared, how it's shared, with whom, and for how long.
I understand that Voices Against Violence has an obligation to keep my personal information, identifying information, and my records confidential. I also understand that I can choose to allow Voices Against Violence to release some of my personal information to certain individuals or agencies.
I (write name), authorize Voices Against Violence to share the following specific information.
Who I want to have my information
Specific Office at Agency
The information may be shared
understand that electronic mail (e-mail) is not confidential and can be intercepted and read by other people.
The information may be shared
in personby phoneby faxby mailby e-mail
What information do I want shared. (List as specifically as possible) Any and all information reguarding housing/case management for Rapid Rehousing.
Why I want my information shared.
I understand:
That I do not have to sign a release form. I am not obligated to allow Voices to share my information. Signing a release form is completely voluntary. That this release is limited to what is written above. If I would like Voices to release information about me in the future, I will need to sign another time-limited releaseThat releasing information about me could give another agency or person information about my location and would confirm that I am recieving services from Voices.That Voices and I may not be able to control what happens to my information once it has been released to the above person or agency, and that the agency or person getting my information may be required by law or practice to share it with others.
This release expires on (Date)
MonthDayYear
Date
(Time)
Expiration should meet the needs of the survivor, which is typically 15-30 days.
Verbal release given to (Advocate name)
(Date)
MonthDayYear
Date
I understand that this release is valid when I sign it and that I may withdraw my consent to this release at any time either verbally or in writing.
Survivor Signature
Clear
Date
MonthDayYear
Date
Witness Signature
Clear
Date
MonthDayYear
Date
Reaffirmation and Extension (if additional time is necessary to meet the purpose of this release)
I confirm that this release is still valid, and I would like to extend the release until
New Date
MonthDayYear
Date
Signed
Verbal release
Signed
Clear
Date
MonthDayYear
Date
Witness
Created for adaptation by the Confidentiality Institute and NNEDV
Should be Empty: