By signing below you hereby authorize voluntarily disclosure of the information in this form for the purpose of being referred to a CT Healthy Living Collective or other chronic disease education/self-management program or service. Information shared may include name, address, phone number, date of birth, primary language and health goals/concerns related to the referral. This personal information may be shared between and among the CT Healthy Living Collective and the program to which you are being referred. You understand the additional information related to the referral, including whether you participated in the programs to which you were referred and the outcome of your participation. You also understand that you may revoke this authorization at any time by contacting the referrer listed above. If you revoke this authorization your personal information will no longer be shared and will be protected by federal and state law.