I hereby authorize Affordable Counseling & Educational Services to disclose records and information obtained
in the course of my participation county certified domestic violence treatment program to:
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
This release shall remain in effect while I am a client of Affordable Counseling & Educational Services and will
terminate upon completion of the program or termination from the program.
& Educational Services