Release Form – 11th Step House

Client's name to disclose to, receive from and communicate with:*

First Middle Last

Individual/organization*

Phone*

Email*

Enter Email Confirm Email

Address*

Street Address City State ZIP Code

The following protected heath information: (please check each that applies)

Other Protected Health Information

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.

Date*

Patient Signature*

Date*

Director Signature*