• Release of Information Other

  • I hereby give my permission for the release of information relevant to providing services and meeting my needs to the staff of the Sexual Assault/Spouse Abuse Resource Center, Inc. This release will be effective for the duration of my program participation.

  • It has been explained and I understand that any information released to a third party can not be guaranteed by SARC staff to remain restricted, as other agencies may not be bound by the same confidentiality requirements.

    I understand that I can choose to revoke authorization to disclose at any time by signing the bottom of this authorization.

  • Clear
  • I wish to revoke this Release of Information authorization at this time:

  • Clear
  • Should be Empty: