Consent
for Release of Confidential Information
Cheung, Clements, and Pechman (1997, p. 39) offer the following sample consent form for the release of confidential information relating to treatment services for alcohol or drug-abuse. This form also is appropriate for students who receive counseling because their parents abuse alcohol or drugs.
"Consent for Release of Confidential Information
I, ____________________________________ authorize
(Name of patient)
________________________________________________ to disclose to
(Name of general designation of program making disclosure)
_____________________________________________________
(Name of person or organization to which disclosure is to be made)
the following information:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
(Nature of the information, as limited as possible).
The purpose of the disclosure authorized herein is to: _________________________________________________________________
______________________________________________________________
(Purpose of disclosure, as specific as possible).
I understand that my records are protected under federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it, and that in any event this consent expires automatically as follows:
___________________________________________________________
(Specification of the date, event, or condition upon which this consent
expires)
Dated_______________________
Signature of participant__________________________
__________________________________________________________
(Signature of parent, guardian, or authorized representative when required)"
