Home > Protecting Children in Substance-Abusing Families > Protecting Children in Substance-Abusing Families : Table 2 : Sample Interagency Consent Form

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Protecting Children in Substance-Abusing Families
User Manual Series (1994)

Author(s):  U.S. Department of Health and Human Services Kropenske, Howard, Breitenbach, Dembo, et al.

Year Published:  1994

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You are in section: Table of Contents Preface Acknowledgments 1 - Introduction 2 - Identifying Alcohol and/or… 3 - Chemically Involved Parents:… 4 - Children of Chemically… 5 - Reporting Child Maltreatment… 6 - Comprehensive Family… 7 - Juvenile Court Involvement… 8 - Innovative Approaches to… Conclusion Appendix I - The Nature of… Appendix II - Sample Medical… Appendix III - Sample Interagency… Notes Glossary of Terms Selected Bibliography Other Resources Table 1 - Hospital Form For… Table 2 - Sample Interagency… Table 3 - Assessment/Intervention… Table 4 - Assessment/Intervention… Table 5 - Assessment/Intervention… Table 6 - Major Substances of…

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Table 2 : Sample Interagency Consent Form

NAME OF CHILD:

________________________________________________________

DATE OF BIRTH:

________________________________________________________

ADDRESS:

________________________________________________________

ADDRESS OF PARENTS, IF DIFFERENT FROM CHILD'S:

________________________________________________________

TO WHOM IT MAY CONCERN:
          I, _________________________, the undersigned juvenile, and I, _________________________, the undersigned legal guardian(s) of the above named juvenile, hereby authorize, unless excluded below, the Juvenile Court Counseling Office, _________________________ County Department of Social Services, _________________________ Mental Health Center, _________________________ County Youth Services, _________________________ County School Personnel, Evaluation Committee of _________________________ County, _________________________ Health Department, and _________________________ (other), or their authorized representatives or employees, bearing this release or a copy thereof, to obtain any information pertaining to my:

           We hereby direct you to release such information upon request of the bearer. The doctrine of informed consent has been explained to us. We understand the contents to be released, the need for the information, and that there are statutes and regulations protecting confidentiality of authorized information. The release is executed with full knowledge and understanding that the information is for official use by the agencies. We hereby acknowledge that this consent is truly voluntary and is valid for one year. We further acknowledge and understand that we may revoke in writing this consent at any time, except to the extent that information has already been released before we revoke it, and except to the extent that action based on this consent has been taken.
           We hereby release you as custodian of such records, any school, institution, hospital, or other respository of medical records, social services agency, any employer, or retail business establishment including its officers, employees, or related personnel, both individually and collectively, from any and all liability for damages of whatever kind which may at any time result to us, or heirs, family, or associates because of compliance with this authorization and request for information or any other attempt to comply with it.
           The information hereby obtained is to be used only for the purposes of investigation, evaluation, and report.

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You are in section: Table of Contents Preface Acknowledgments 1 - Introduction 2 - Identifying Alcohol and/or… 3 - Chemically Involved Parents:… 4 - Children of Chemically… 5 - Reporting Child Maltreatment… 6 - Comprehensive Family… 7 - Juvenile Court Involvement… 8 - Innovative Approaches to… Conclusion Appendix I - The Nature of… Appendix II - Sample Medical… Appendix III - Sample Interagency… Notes Glossary of Terms Selected Bibliography Other Resources Table 1 - Hospital Form For… Table 2 - Sample Interagency… Table 3 - Assessment/Intervention… Table 4 - Assessment/Intervention… Table 5 - Assessment/Intervention… Table 6 - Major Substances of…

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Updated on December 10, 2007