SUPPORTED BY CHILDREN IN CRISIS

CONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATION

I,
client or legal guardian of
do hereby authorize Kay Phillips Child Advocacy Center to disclose/release the following information:
to
concerning the above named child(ren) and/or myself. The purpose of the disclosure/release is to:
I understand that client records at Kay Phillips Child Advocacy Center are classified as either Mental Health records or Forensic Interview records. Forensic records are protected under evidentiary rulings and Mental Health records are protected under the Health Insurance Portability and Accountability Act of 1996 (HIPPA), 45C.F.R., Parts 160 and 164. I understand that I may revoke this consent in writing at any time except to the extent that action has been taken in reliance on it, and that in any event this consent expires automatically as follows:

I understand that, generally, this agency may not condition my treatment on whether I sign a consent form, but that, in certain limited circumstances, I may be denied treatment if I do not sign a consent form

Client/Legal Guardian Signature
Clear
Client/Legal Guardian Signature
Clear

Date: 04/28/2025
Please check.