I hereby authorize the release of information concerning myself and my dependents as necessary for the purposes of general case management and for participation in Supportive Guidance programming and services. I understand that case management may include the participation in many agencies.
This authorization specifically includes records prepared prior to the date of this authorization and reords prepared after the date of this authorization. This form gives the staff of Supportive Guidance authorization to receive information from and share information with the individuals/agency listed below. I understand that I may revoke this consent in writing. I also understand that without the information Guiding Principles and cooperating agencies may be unable to provide me or my dependents with the services I am requesting. A photocopy of this authorization will be treated in the same manner as the original.
Release expires one year from date signed.
