Limited Release Form

Client Information Client Information I understand that ETCC has an obligation to keep my personal information, identifying information, and my records confidential. I also understand that I can choose to allow ETCC to release some of my personal information to certain individuals or agencies.

First Name

Initial Last

Email Address

Osnium #

Name

Specific Office at Agency

Phone Number/Email

Name

Specific Office at Agency

Phone Number/Email

ETCC may share information: ETCC may share information: In Person By Phone By Fax By E-mail (if you choose this method you have to check the box below) I understand that electronic mail is not confidential and can be intercepted and read by other people.

ETCC can share the following info:

Reason for sharing info:

I Understand: I Understand: That I do not have to sign a release form. I do not have to allow ETCC to share my information. Signing a release form is completely voluntary. That this release is limited to what I write above. If I would like ETCC to release information about me in the future, I will need to sign another written, time-limited release. That releasing information about me could give another agency or person information about my location and would confirm that I have been receiving services from ETCC. That ETCC and I may not be able to control what happens to my information once it has been released to the above person or agency, and that the agency or person getting my information may be required by law or practice to share it with others.

Consent Consent I understand that this release is valid when I sign it and that I may withdraw my consent to this release at any time either orally or in writing. I agree to the statement above.

Date