Waiver of Confidentiality

Initial Contact
Program Contract
Waiver of Confidentiality
Program Policy

Consent to Release of Information

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.