Release Form

Release Form

  • The purpose of this disclosure of information is to improve assessment and treatment planning, share information relevant to treatment and when appropriate, coordinate treatment services. I understand that I may withdraw this consent at any time, either verbally or in writing except to the extent that action has been taken in reliance on it. This consent will last while I am a resident at the 11th Step House, unless I withdraw my consent during my residency. This consent will expire 365 days after I complete me stay. I understand that the records to be released may contain information pertaining to my alcohol and/or drug dependence recovery process. These records may also contain confidential information about communicable diseases including HIV (AIDS) or related illnesses.