Consent for the Acquisition and/or Release of Information
Client Name
First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Date today
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Month
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Day
Year
Date
I hereby authorize Pavilion to obtain information from and/or release information to:
DTSSAB (Housing)
Legal Aid
Ontario Works
Victim Services
OPP
NEOFACS
CMHA
Please provide specific names (e.g. Dr. Jane Jones, Susan Jones, Lawyer)
Please be specific about who we can share information with.
Type of information that can be requested/disclosed (e.g. information about my situation, information about my counselling attendance)
We will only share the information that you want us to share so please be specific.
Signature of Client / Subject
Clear
Date Signed
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Month
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Day
Year
Date
Submit
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