Special Angels - Counseling Release Authorization

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Client Name: * 🛈

Date of Birth: *

Phone Number: *

Alternate Phone Number:

Email Address *

Authorization for Release of Records/Information

I, the undersigned, give my permission for Sarah Cholevik to provide the following information to
Special Angels Adoption for the purpose of assisting in my consideration of an adoption plan:

Please Initial Each Type of Information You Are Willing to Share:

	Initials
Information about my reasons for considering adoption	Initials
Information about my current state of mind	Initials
Information that could affect my ability to move forward with an adoption plan	Initials

I, the undersigned, also give permission for Special Angels Adoption to share my intake form with Sarah
Cholevik for the purposes of assisting in providing the best possible supportive care.

I understand that specific information will not be disclosed/discussed with any other parties, other than
as indicated above. However, due to mandatory reporting laws, I understand if I disclose any thoughts
of self-harm, to include suicidal or homicidal thoughts, the limits of confidentiality will not apply due to
these mandatory reporting laws. Futhermore, if any child abuse allegations are disclosed there are also
mandated reporting laws and this information would have to be reported and confidentiality breached
due to these laws.

This authorization will be in effect from the date of signing for up to one calendar year. I can revoke this
consent at any time by notifying Sarah Cholevik verbally or in writing but understand that information
may have already been release. Revocation does not apply to anything that falls under mandatory
reporting.

Date: * +

Client Signature: *

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