M.C.

S Youth Counselling Services & Emergency Shelter

Consent to Disclose Information

I, _____Jack DaCosta_____________________ ____________17/08/2003_____ allow

(Client’s full name) (Client’s DOB)

_____Andrew Gauvreau_____________ From: M.C.S Youth Counselling Services & Emergency Shelter

(Worker’s name) (Name of Agency)

To disclose information gathered during my counselling sessions/meetings to:

_____Bill Santos__________ ________ From: ___Rosedale School For The Arts_____.

(Worker’s name) (Name of Agency)

I consent to the disclosure of the following types of information:

Family concerns, general needs and concerns ____________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
________________________________________________________________________________________________.

From; ______16/10/2018_________ to: _____15/11/2018___________

(Date authorized) (Expiry date)

Signature: ___________________________________________

Witness:_____________________________________________

Guardian Signature (under 16):____Follow Up Needed___