_HOPE COUNSELING SERVICES - Bloomington , IN
Crisis Pregnancy Center of Bloomington, Inc.
Hannah House Maternity Home
808 North College Ave.
Bloomington, IN 47404
CPC: 812-334-0104
Hannah House: 812-334-2662
CONSENT FOR EXCHANGE OF CONFIDENTIAL INFORMATION
I, ___________________________________ hereby authorize Crisis Pregnancy Center of Bloomington, Inc. and Hannah House Maternity Home to exchange confidential information relevant to me with the following individuals/agencies/entities:
Name of agency/individual/entity:
Please initial all. If resident is a minor, parent/guardian must initial all.
____ WIC
____ Center for Behavioral Health (Centerstone)
____ Bloomington Meadows Hospital
____ Center for Women’s Ministries
____ Obstetrician, Dr. __________________
____ Indiana University Health Bloomington Hospital
____ Healthy Families
____ Department of Child Services (DCS)
____ Family and Social Services Administration (FSSA)
____ Monroe County Community School Corporation (including BLC, BHSN, Aurora)
____ Dr. __________________________
Please include all agencies not listed above where you have received services or treatment in the past or present.
____ Other (initial by each):____________________________________________________________________
______________________________________________________________________________________________
Information to be exchanged:
Any and all information and records regarding my medical, mental health, alcohol/drug abuse, communicable diseases including but not limited to AIDS/HIV, psychiatric, educational, vocational, or human services care.
This consent expires upon my exit from the Hannah House program unless specifically revoked, in writing, on an earlier date.
_________________________________________ Date:___________________
Resident Signature
__________________________________________ Date:___________________
Signature of parent/guardian, if client is a minor
__________________________________________ Date:___________________
Hannah House Director or Assist. Director Signature
................
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