Non-profit victim service agencies, advocates, and partnerships that provide services to survivors of domestic violence, dating violence, sexual assault and stalking may adapt these forms, policies and agreements for immediate use.  Use Step-by-step easy instructions!

Client Limited Release of Information Form

This form is used to help a client assess risks and benefits of having an agency release some of her/his confidential information to another individual/agency. The form enables the client to choose what information an agency may share, how it is shared, with whom, and for how long.

Your agency and collaborative community response partners are encouraged to adapt and use this model form. To adapt this template for use, simply:

  1. add information relevant to your specific agency, partnership and funders;
  2. insert your [program/agency/partnership/collaboration names] and letterhead;
  3. remove any generic template blue instruction notes and other notices from us;
  4. if needed, minorly change certain words like victim to match the language your agency or partnership prefers (e.g. client, victim, survivor, service participant).

Download adaptable template form: