Consent for the Release of Confidential Information

I hereby authorize my probation officer, DHSS caseworker, Pathways caseworker, lawyer, counselor, my medical clinic, and WIC to release on my behalf information pertinent to my residency, health and well-being and case management progress to the staff of:

The Pregnancy Support Center

525 S. Washington Ave.

Lebanon, MO 65536

417-532-8555

I also authorize the staff of the Pregnancy Support Center staff to release on my behalf information pertinent to my residency, health and well-being and case management progress to my probation officer, DHSS caseworker, Pathways caseworker, lawyer, counselor, my medical clinic and WIC.

I understand that my records are protected and cannot be disclosed without my consent unless circumstances require by law for information to be released.  I also understand that I may revoke this consent in writing at any time.

This consent expires automatically upon termination of residency at My Sister's House Maternity Home or Project Thrive.