I hereby authorize Affordable Counseling & Educational Services (ACES) to disclose records and information obtained in the course of my participation county certified domestic violence treatment program to:

• Appropriate Courts
• Probation Officer
• Attorney
• Parole Officer
• The Identified Victim
• Officers of the Courts

This disclosure of the records authorized herein is required to inform the courts and those agencies/agents directly involved of the participant’s status in the program. Such disclosures include but are not limited to the following:

• Notification of Enrollment
• Progress Reports
• Terminations
• Documentation of Incidents
• Completions
• Recommendations of Concurrent Programs
• Information necessary to protect/warn the victim of domestic violence keeping in compliance with the Tarasoff decision.
• All information requested by the courts or probation department
• All persons identified and authorized by myself
• Mandated Reporting requirements

This release shall remain in effect while I am a client of ACES and will terminate upon completion of the program or termination from the program.