Today's Date *

MM

DD

YYYY

Referrer's Phone Number *

(###)

###

####

Patient/Client's Name *

First Name

Last Name

Patient/Client Date of Birth *

MM

DD

YYYY

Patient/Client Address *

Or closest city

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Patient/Client Phone Number *

(###)

###

####

Infant's Name

If applicable

First Name

Last Name

Infant's DOB or Due Date *

MM

DD

YYYY

Consent to leave a voicemail *

Yes

No

Consent to text *

Yes

No

I request to authorize (referring agency) to release information of the above named client/patient to Step By Step Family Support Center. *

Yes

This request authorization applies to: *

All health care information

Other

I further authorize the exchange of information between (referring agency) and Step By Step Family Support Center *

Yes

No

Because of protection by state/federal law, I understand that my express consent is required to release any health care information relating to testing, diagnosis, and/or treatment for HIV (AIDS virus), sexually transmitted diseases, psychiatric/mental health, or drug and/or alcohol use. If I have been tested for any of these, you are specifically authorized to release all health care information relating to such diagnosis, testing or treatment. *

ok to release

Yes

No

This consent expires on the date below or 90 days from signed date, whichever occurs first. I understand that this consent may be revoked by me at any time (except to the extent that it has already been acted upon) by submitting a written request to the referring agency. *

MM

DD

YYYY