CONSENT FOR RELEASE OF INFORMATION

I certify that I have consulted with my social worker, and I consent to the release of confidential information concerning myself or Safety Planning, and Service Coordination.

I CONSENT TO RELEASE AND TO COLLECTION OF CONFIDENTIAL INFORMATION BETWEEN MAMAS FOR MAMAS & THE FOLLOWING PROFESSIONAL/INDIVIDUAL AND/OR SERVICE PROVIDERS FOR THE PURPOSE DESCRIBED ABOVE: Lawyer, Police Victim Services, Hospital / Doctor, MCFD, Counsellor, Housing Programs, Community Programs related to the situation