CAPIT & CPS Release of Information

First Name

Last Name

	First and Last Name	Date of Birth
client Client's First and Last Name	Client Name	Date Field
Text Label Minor A's First and Last Name	Enter a Value	Date Field
Text Label Minor B's First and Last Name	Enter a Value	Date Field
Text Label Minor C's First and Last Name	Enter a Value	Date Field
Text Label Minor D's First and Last Name	Enter a Value	Date Field

AUTHORIZATION is hereby given for verbal / written information regarding the client's case to be exchanged / released between The Center for Violence-Free Relationships (The Center) and the following parties:

El Dorado County Child Protective Services

El Dorado County, CAPIT (Child Abuse Prevention, Intervention, and Treatment) Program

This release is not an authorization for The Center's representatives to provide testimony in court.

The Center may provide services paid for by a contract between The Center and The County of El Dorado. I agree to have my name, demographic infomration, service dates and types, service goals, and progress toward these goals shared with The County of El Dorado. I understand that no other personally identifying information will be shared without by separate written consent, except for the following reasons:

* Court Order
* Confidential auditing from third party payers.

THIS AUTHORIZATION EXPIRES ON: 07/03/2025 2:11 PM

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