Adult Authorization For Release Of Information Form - Casa Lake County
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1CASA Lake County
ADULT AUTHORIZATION FOR RELEASE OF INFORMATION
I, ______________________________________________, DOB, ____________________, authorize
(Client’s Name)
(date of birth)
CASA Lake County, 1020 Milwaukee Ave,, Deerfield IL 60015 (847-808-9154) and
24647 Milwaukee Ave., Vernon Hills, IL 60061 (847-377-7975) to:
X Send
X Receive
to/from the following agency and/or person:
(agency name and/or person)
(Address)
(City)
(state)
(zip)
(Telephone number)
Specific nature of information to be released:
Family/Social History
Progress/Prognosis Reports
Substance Abuse History
Investigation Reports
Substance Abuse Treatment
Psychiatric/Psychological Reports
Laboratory Reports/Results
Treatment Plans
Case Service Plans
Other: any information pertinent for decision
making in Juvenile Court regarding
parenting capability, capacity,
family reunification
Attendance Records
Other______________________________________
The above information will be used for the following purposes:
X Reporting to Juvenile Judge
X Advocating on behalf of involved children
Other_____________________________________________________________________________
Consequences of refusal to sign:
None
Will be reported to Juvenile Court Judge
Other________________________________
This authorization is valid until: Month: _________ Day: _____ Year: _________
Signature:____________________________________________
Date:_________________
Signature of Witness:___________________________________
Date:_________________
I understand that I may revoke this authorization at any time by providing written notice.
I withdraw this authorization, effective ________ Signature:______________________________________________ Date:____________________
I understand that released information may not be redisclosed to any other person or organization without my written consent. (This is in
compliance with the Federal Regulations Governing the Confidentiality of Alcohol and Drug Abuse patient records, as noted in 42 CFR, Part
2.32 (s) or in compliance with the Illinois Mental Health and Developmental Disabilities Act.)
I understand that I have a right to inspect and/or receive a copy of the information to be released and also receive a copy of this
authorization.
I understand I may refuse to sign this authorization and I understand my refusal to sign will not affect my child’s access to an advocate.
A Member of the National Court Appointed Special Advocate Association
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