In order to provide for the best care and protection of the children in our community, the SAFEchild Advocacy Center collaborates with a multi-disciplinary team (MDT) made up of medical providers, the Department of Social Services, law enforcement, prosecutors, mental health providers, victim advocates and others. The purpose of this release is to facilitate the sharing of information by the agencies participating in the MDT in order to provide for the best treatment and protection of the child named above.
I hereby authorize the SAFEchild Advocacy Center to release/exchange information pertaining to suspected physical or sexual abuse and/or neglect obtained during the medical evaluation, forensic interview or Child/Family Evaluation that may facilitate the diagnosis, treatment, investigation and/or court intervention of child maltreatment to the agencies, organizations and individuals named below and initialed by me. It may also be used for training and education. I understand that this may include information regarding drug/alcohol abuse, sickle cell anemia, abortion, genetics, tuberculosis, psychological and psychiatric conditions, sexually transmitted diseases, including HIV/AIDS, domestic violence and issues involving abuse and neglect. This may include pictures, recordings and video, which may be used to document the assessment.
I understand that there are laws requiring SAFEchild Advocacy Center to release/report information to the Department of Social Services and appropriate Law Enforcement agencies where child abuse and neglect is suspected.
I also understand that SAFEchild Advocacy Center may release the child’s medical information to any licensed provider or facility to which he or she may be referred for further medical and mental healthcare.