Informed Consent and Information Release

I,______(client), hereby give ______(agency)permission to contact any persons or agencies I may be working with in order to improve my ability to become self-sufficient. I also give my permission for these agencies to exchange information about my case and circumstances in order to seek the resources that I might need at this time. These agencies includes:

Monticello Area Community Action Agency (MACAA), Salvation Army, UVA Health System, Martha Jefferson Hospital, Department of Social Services, Region Ten, Charlottesville City Housing Authority, Albemarle Housing Authority, Charlottesville City Schools, Albemarle County Schools, Charlottesville Free Clinic, Love Inc., ABCC, CARES, Veterans Administration, On Our Own, Social Security, Legal Aid of Central VA, Offender Aid and Restoration (OAR), Piedmont Housing Authority, The Haven, Shelter for Help in Emergency (SHE), AIDS Services Group (ASG), Equity, The Mohr Center, The Crossings Single Resident Occupancy (SRO), and Virginia Supportive Housing. I give permission to disclose or discuss any relevant personal information with the understanding that I can revoke this permission in full or in part at any time. This permission is in effect for three years from the date of signature.

Signature: ______Date: ______

I authorize [agency] personnel to release the following confidential information as that of their efforts to help me locate and maintain housing. I authorize release of information only to those agencies or individuals listed below.

Information can be disclosed/released to:

To Community Case Review including DSS, Equity, PACEM, The Haven, and TJACH

(Names of Agencies/Persons)

Disclosed specified information limited to:

Contact information

Financial Information

Employment information

Support Needs

Household composition

Purpose/Need for Disclosure: To determine housing needs and to secure housing.

My signature below authorizes DHCD and the Housing Assistance Program to release specified information to agencies and individuals noted above. Further, if I am unable to participate in a determination of those services which would be of benefit to me, or my permission is needed in the future to authorize additional services for this program, my signature below authorized the Housing Assistance Program to sign for assistance for me in my absence after receiving my verbal permission. This consent expires three years from today or when revoked in writing by the authorized person, or upon exit from the program. This authorization can be cancelled at any time in writing, however the cancellation will not affect any disclosures already made prior to the cancellation notice.

X / Client Name
Client Signature / Date
Care Coordinator Name
Care Coordinator Signature / Date

Pathways Authorization Form

IunderstandthatPACEM, The Haven, Equity, and Region Ten arepartofthe Thomas Jefferson Area Coalition for the Homeless (TJACH) and Pathways Community Network,acomputer network designed to reduce the amount of time and effort it takes for me to obtain the social services I need.
Theseagencieshavemypermissionto:
-LookatinformationaboutmeinthePathwayssystem
-Enterinthesysteminformationconcerningmysituationandneedforassistance

Iunderstandthat:
- AgenciesinthePathwayssystemwillkeepthisinformationconfidential. Otheragencieswillbeable tolook atthisinformationonlyifIgiveeachofthese agenciesmypermission.
- Staffateachagencyreceivesregulartrainingonclientconfidentialityandtheirlegal responsibilityto keep myinformationprivate
- ThePathwayssystemusespasswordsandcomputerizedcodestoprotectmyprivacy. Shared
information mayincludemyname,age,gender,maritalstatus,veteranstatus, address, housingstatus,
andbasicinformationaboutmygoalsandtheservicesIreceive
- IcanobtainacopyofinformationaboutmecollectedbythePathwayssystem,except for
psychotherapy notesandotherinformationkeptprivatebylaw.

IalsounderstandthatIhavetherighttorefusetograntthisauthorization,andthatevenifIgive permission forthisagencytoaccessmyinformationinthePathwayssystem,Icanrevokethat permission atanytime,withoutpenalty.ThepermissionIamgivingthisagencytoviewmy information
andtoplaceinformationaboutmeinthePathwayssystemwillexpirethree years from the date I sign.

I alsounderstandthatundercertaincircumstances,thisagencyorPathwaysmaybelegally required
to disclosesomeorallofmyconfidentialinformation.Thismayhappenifthereisany evidenceof child
abuse,ifthereisevidenceImayharmothersormyself,orifacourtorders thatmy information be disclosed.

Inordertoimproveservicesforpersonsinneed,expertsmaystudydatafromthePathways systemand
othersources.Asaresult,anindependentresearchermayneedtoviewpersonal information,such asnamesandSocialSecuritynumbers,tomakesurethatrecordsarenot countedtwice.This
researcher willremoveallpersonallyidentifiableinformationbeforeanyone elseexamines thedata,
sothattheprivacyofthosewhoreceivedservicesisprotected.This procedureisdonein accordance with professionalstandards,understrictgovernmentand researchinstitution supervision,and in compliance withallregulationsthatspecificallyaddress thosewhohave receivedservices formental health,substanceabuse,HIV/AIDS,anddomestic violence. Iauthorizethis agencyto viewmy information andtoplaceinformationaboutmeinthePathwayssystem.
Signature: ______Date: ______

PrintName: ______DateofBirth: ______

WitnessSignature: ______Date: ______

Rev. 8/13