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:

• Appropriate Courts
• Attorney
• Officer of the courts
• Child Protective Services

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: :

• Dates and length of visits
• Notification of Initial Contact
• Terminations
• Documentation of Incidents
• Information necessary to protect/warn the victim of domestic violence keeping in compliance with the Tarasoff decision.
• Mandated Reporting requirements

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.