Request and Authorization for Release of Confidential Information

Fremont Family Coalition

Community Response




Request and Authorization for Release of Confidential Information

I, ________________________ DOB_______________ hereby authorize the reciprocal release of information contained in these records between the Fremont Family Coalition of Dodge County, NE lead by United Way and its partnering agencies.

Assessment, services and case management for connections to community resources
The purpose for such disclosure is:

__________________________________________________________________________________________________________________________________________________________________________

This consent allows your information to be shared between the Fremont Area United Way and any partnering agencies within or outside of the Fremont Family Coalition of Dodge County, NE that may assist with your treatment. See page 2.

I have been provided with the names of the community partners that may assist with helping me reach my goals. Initials______

I have had the opportunity to review the list and cross off the agencies that I do not want to share my information with. Initials______

Witnessed by Signature

Date Witnessed Date Signed

Parent Signature (for juveniles only)

Date Signed

Without expressed revocation, this consent will expire one year from date of signature

Community Response Team

Care Corps Family Services

Dodge County Head Start

Heartland Family Services

Low Income Ministry

Lutheran Family Services

Pathfinder Support Services

Uniquely Yours Stability Support

All Other Service Providers/Informal Supports

City of Fremont

Crisis Center/The Bridge

Dodge County Attorney’s Office Dodge County Probation

ESU2-University of NE Fremont Public Schools

Hills Counseling Low Income Ministry

Mary Haskins, LCSW LADC Michele Missel, LMH LCSW

Munroe Meyer Institute

Nebraska Children and Families Foundation

Nebraska Department of Health and Human Services Nichole Gregory, LADC

Park Professional Group

Rebuilding Together Schmeeckle Research Three Rivers District Health Department Uniquely Yours Stability Support University of Nebraska

YOUTH and FAMILY CR 11/15