Alliance For Children CST Services Coalition Consent to Services and Release of Information Form

Consent to Services and Release of Information for Tarrant County MDT Services Coalition
Staff Name
Phone Number
Area CodePhone Number
Staff Email
example@example.com
Agency
TCJSDFPSAdvocate AgencyOther
Child Information
Child's name*
First NameLast Name
Date of Birth*
MonthDayYear
Date
Mobile number
E-mail
Residing
Own homeShelterOther
Guardian Information
Guardian name*
First NameLast Name
Date of Birth
MonthDayYear
Date
Address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Phone Number*
Area CodePhone Number
Email
example@example.com
Consent for Services
I would like to approve sharing of information between and referral for services for the following agencies:
ACH Child and Family Services
Alliance For Children
CASA Tarrant County
City Square
Department of Family and Protective Services
Lena Pope
MHMR Tarrant County
One Safe Place
Tarrant County Juvenile Services
Traffick911
UnBound
Women's Center
Additionally, I would like to approve sharing of information between and referral for services for the following agencies (if not listed above):
I understand this information and any subsequent records are confidential and cannot be disclosed without written authorization, except otherwise as stipulated by law. This consent allows for the exchange of information by providers for the purpose of service provision. This consent may be revoked at any time.
Guardian Signature
Clear
Should be Empty:

Consent to Services and Release of Information for Tarrant County MDT Services Coalition