What should I do if I provided services for domestic violence, sexual assault, and/or stalking and the standard consent form (DCH-3927) isn't right for the person who received these services?

First, have a discussion with the person about the risks and benefits of a release, in light of the following questions:

  • How will sharing the information help the person reach her/his goals?
  • Will the provider to whom the information is released keep the person’s information confidential? If not, with whom might it be shared?
  • How might the information be used against the person?
  • Will releasing the information allow the abuse perpetrator easier access to the person’s records, including more information than was authorized by the release? (For individuals involved in court cases, a release that is overbroad may result in a waiver of any privilege that may otherwise have protected the records.)
  • Are there ways to accomplish the person’s purposes without sharing the information at issue?  Consider the following options:
    • Can I verbally and directly share the information with the prospective recipient in a phone call, or during a face-to-face appointment?
    • Is the information otherwise available from a non-confidential source?
    • Can the person provide the information needed by way of an independent letter or other written document, clearly stating that it is not part of the provider’s files or records?

If you and the person who received your services decide that a release is necessary, take these steps:

  • Review the contents of the file or any other relevant information with the person to determine the minimum amount needed to accomplish the person’s purpose.
  • Give the person an opportunity to correct inaccurate or incomplete information.
  • Determine how much time will be needed to accomplish the person’s purpose and limit the duration of the release to that period.
  • Limit unnecessary multiple disclosures, and use a separate release form for each one.
  • Use a release process and form that has the following characteristics:
    • An individual’s consent to share information must be voluntary and revocable at any time. Provision of services must not be conditioned upon signing any release.
    • The release should contain specific beginning and ending dates, and be limited to a period not to exceed 30 days. If more time becomes necessary, the release should provide for the individual to extend its duration.
    • The release should describe the information to be shared as specifically and narrowly as possible. Blanket releases of information are unsafe.
    • The release should describe the purpose for the release as specifically and narrowly as possible.
    • The release must clearly identify the recipient of the information at issue. To avoid confusion arising from differing confidentiality restrictions among care providers and inadvertent disclosures, the information released must be limited to one recipient. Separate forms should be used for multiple recipients of information.
    • The release should identify the means by which the information will be transmitted (e.g., verbally, in writing, electronically, etc.).
    • The release should provide places for both the individual and provider to sign and date it.

To mitigate the risks of disclosure, releases of information for individuals who have experienced domestic violence, sexual assault, and/or stalking must be written, and limited to a specific time and purpose. Additionally, these individuals should be fully informed about all aspects of any disclosure, so that they can take adequate measures to safeguard themselves against possible negative consequences.

A sample written release form has been developed for adaptation by the National Network to End Domestic Violence (available in English and Spanish).