CONFIDENTIAL

CONSENT FOR Client Code: Incident

RELEASE OF INFORMATION ___________ No:
__________

This form should be read carefully and clearly explained to the client.

I, ___________________________________________________________, give my
(Name of client or parent/guardian)

permission for
________________________________________________________
(Handling organization)

to share information about me and the incident that I reported to them to other
service providers that they deem appropriate so that I can receive help on safety,
health and psychosocial, legal, and other needs.

I also understand that shared information will be treated with confidentiality and
respect, and shared only as needed to provide the assistance that I need.

Signature/thumbprint of client: ____________________________

Date signed: ____________________________

Note: The parent or guardian will sign the consent form if the client is a child below
18 or as defined by RA7610.

 Check this box if the client refused to sign the consent form. Indicate reason/s for
refusal:
________________________________________________________________
________________________________________________________________
________________________________________________________________

Note: Do not attach the Consent Form for Release of Information directly to the
Intake Form. It should be stored separately to ensure client confidentiality.
 CONFIDENTIAL

CONSENT FOR Client Code: Incident

RELEASE OF INFORMATION ___________ No:
__________

Ang form na ito ay dapat basahin nang mabuti at malinaw na ipinaliwanag sa

kliyente.

Ako si ________________________________________, binigbigyan ng pahintulot

(Pangalan ng kliyente o magulang/tagapag-alaga)

ang ____________________________________________________
(Organisasyon na may hawak ng kaso)

na magbahagi ng impormasyon tungkol sa akin at sa mga pangyayari na inulat ko sa

kanila sa iba pang mga service providers na makatutulong sa aking kaligtasan,
kalusugan at psychosocial, legal at iba pang mga pangangailangan.

Nauunawaan ko na ang ibinahagi kong impormasyon ay mananatiling pribado at

ibabahagi lamang kung kinakailangan at makatutulong sa akin.

Lagda o thumbprint ng kliyente: ____________________________

(Petsa): ____________________________

Paalala: Ang magulang o tagapag-alaga ang lalagda ng consent form kung ang
edad ng kliyente ay 18 pababa o ayon sa depinisyon ng RA7610.

 Lagyan ng tsek ang kahong ito kung ang kliyente ay tumangging pumirma sa
consent form. Ilista ang dahilan o mga dahilan ng pagtanggi:
________________________________________________________________
________________________________________________________________
________________________________________________________________

Paalala: Huwag isama ang Consent Form for Release of Information sa Intake
Form. Ito ay dapat hiwalay na nakatago upang masigurado ang client
confidentiality.