Travis County Counseling & Education Services
P.O. Box 1748, Austin, TX 78767 (512) 854-9540; Fax 854-9146
Caryl Clarke Colburn, Director
CONSENT FOR THE RELEASE
OF CONFIDENTIAL INFORMATION
(Allow TCCES to Release Confidential Information to Non-Criminal Justice Entity)
I, authorize
(Name of Client) (Date of Birth)
Counseling & Education Services of Travis County to disclose to:
______________________________________________________________________________________
(Name organization and name of person which disclosure is to be made)
the following information limited to: the alcohol/drug and/or family violence assessment results (CES
Summary Report) for ___________________________:
(Cause #)
The purpose of the disclosure authorized herein is to: _________________________________________
(Purpose of Disclosure, as specific as possible)
____________________________________________________________________________________
I understand that my records are protected under the federal regulations governing Confidentiality of Alcohol &
Drug Abuse Patient Records, 42 CFR Part 2, and cannot be disclosed without my written consent unless
otherwise provided for in the regulations. I also understand that I may revoke this consent at any time except to
the extent that action has been taken in reliance on it, and that in any event this consent expires automatically on
____________________.
Dated: ____________________ ___________________________________
Signature of participant
___________________________________
Signature of parent, guardian or authorized
Representative when required
Dated: _____________________ ___________________________________
Signature of Witness
White - Client
Yellow - TCCES File
rev. 12/13
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