READ FIRST: DVRC must keep information about you private. The only time your personal information should be shared is when you want us to for specific services or if we are compelled by law or court order.

· You never have to agree to share your information. We will still help you and provide our services.

· If you do want DVRC to share some information about you, use this form to give instructions about what you do and don’t want shared, and with whom you want it shared.

· Before you sign this, someone at DVRC will discuss your goals/needs, your choices for how to meet those, and the pros and cons of having us share the information for you.

· You can change your mind about what you want shared at any time, and we will update this form to reflect your decision.

Limited Release Of Information Form

These are my instructions for Domestic Violence Resource Center of South County (DVRC) to share my information:

I want this information shared: