Information Release Authorization

I, ________________________, authorize dARSW to exchange information with:
Person and/or Agency: ________________________
Address: ________________________
Phone: ________________________

The following checked items indicate information to be exchanged or released.
(Please strike out items not requested.)

Information regarding past and/or current services
Medical history
Social/family history
Mental Health Records
Educational/school records
Substance Abuse History
Criminal Record Check/Police Report
Employment History
Rental History
Credit History
Financial Management/Payee Services
Other (Please Specify): ________________________

This authorization is valid while receiving services from dARSW, and for 90 days following the close of my file, unless my consent is withdrawn (in writing), or unless a date is otherwise specified below.
Date specified(if any): ________________________

I understand that by signing this completed form, I will allow the sharing of confidential information with the person and/or agency listed above.

________________________
Consumer Signature and Date


________________________
Counselor Signature and Date

2700 NE Andresen Rd, Suite D5, Vancouver, WA 98661
(360) 694-6790 Voice
(360) 882-1324  fax/tty

disabilityresources@darsw.com