Management Referral Release of Information

Management Referral

Release of Information
Employee Name:
Date:

MonthDayYear
Date
Company/Employer:
I understand that I am being referred to Human Development Company by my supervisor for concerns impacting the workplace. As a part of my work with Human Development Company, I understand that communication between my Supervisor and HDC are essential. I understand that communication between my affiliate counselor and HDC is also essential.

Examples of the details that may be shared (but are not limited to) include:

1. Scheduled appointments and attendance.

2. Recommendations to supervisor regarding workplace resolution.

3. Your compliance with the counselor’s recommendations.

4. Your discharge summary.

I authorize Human Development Company to release my information to:
Supervisor:
Supervisor Phone:
Other employee:
Other Employee Phone:
Affiliate Counselor:
Affiliate Counselor Phone:
I understand that this Release of Information will be valid from today’s date until six months from now. I understand I have the right to rescind this release at any time for any reason by calling 502-589-4357. I also understand that this referral is part of an effort to improve my job performance and/or workplace behaviors.
Signature:*

Clear
Date

MonthDayYear
Date
Should be Empty: