Consent for Release of Information * I give permission to exchange educational and psychosocial diagnostic, assessment, and treatment information, as well as descriptive information about symptoms and behaviors regarding: First Name Last Name I hereby declare that I am the: * (Check only one box.) Parent Legal Guardian This information may be obtained from and released to: Agency: * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Fax (###) ### #### This information may be obtained from and released to: Compeer Rochester, Inc. (Staff, Interns, and Volunteers) 259 Monroe Ave Rochester, NY 14607 Phone: 585.546.8280 Fax: 585.325.2558 Agreement Compeer Rochester must report to its funders to ensure continuation of services. In addition to agency staff, client names and service hours may be shared with licensed researchers and authorized funders in order to measure the impact of mentoring in our community. Compeer Rochester honors client privacy and will never share detailed information about a client’s mental health status or diagnoses with any parties not authorized by the client or client’s guardian. By signing below, I understand and agree to the above content and authorize the ongoing release of information for the purpose of finding a volunteer mentor for myself or for my child, and also to support the volunteer throughout the duration of his or her match with me or my child in the Compeer Program. This consent expires when Compeer services are discontinued. I understand that I have the right to revoke and or restrict this authorization at any time, provided that I submit a request in writing to the referring agency. Any revocation shall not apply to the extent that the referring agency has already taken action in reliance on this authorization. Parent/Guardian E-Signature * First Name Last Name Thank you!
