Required fields are marked with asterisks (*)

Family Services Durham Client Consent to Disclose Information

I fully understand the purpose for the disclosure of information I am authorizing and give my consent voluntarily. I understand I am not obligated to sign this consent form.

I understand that this consent may be withdrawn at any time by me or by Family Services Durham and that withdrawal of consent is not retroactive and may be subject to exceptions. I understand that unless revoked, this consent will remain effective from the date of signing for one (1) year.

NOTE: Each person providing this consent must submit a separate form.

I (enter your first and last name or alternate decision maker - required)

consent to the release of (enter the information to be disclosed - required)

regarding (enter the first and last of the client - required)

for the purpose of (enter the reason for disclosing this information - required)

I agree that an authorized representative of Family Services Durham has my authority to disclose information to (enter the name of the agency/person - required)

Add Remove

I agree that the agency/ person listed below has my authority to disclose information to an authorized representative of Family Services Durham. (enter the name of the agency/person - required)

Add Remove

By signing below, I acknowledge I have read and understood the above and acknowledge that if signing on behalf of a minor or incapable person I have the authority to do so.

Enter your first and last name (required):

Date (required):

Enter your primary email address (required only if signing electronically):

I acknowledge that checking this box has the same force and effect as signing the document in person (required only if signing electronically):

I agree

Add your signature:

Clear

Personal information contained on this form is collected pursuant to the Municipal Act 2001, and in accordance with the Municipal Freedom of Information and Protection of Privacy Act (MFIPPA). Personal information on this form will be used to assist Family Services Durham in determining eligibility and approval for counselling and may be subject to disclosure under the MFIPPA if circumstances warrant. Questions regarding the collection, use and disclosure of personal information should be directed to the Corporate Privacy Office at foi@durham.ca, 905-668-7711 ext. 2204 or 1-800-372-1102.

If you require this information in an accessible format, please contact Family Services Durham at 905-668-7711 ext 2709.