|
SAMPLE |
||||||
|
CONFIDENTIALITY RELEASE FORM |
||||||
|
This release is a sample that Catholic Social Agency of Allentown has used when attempting to gather information for the child profile. Agencies have found it helpful to get written support from the County, which is then attached to your individualized release form, which specifies the information you are requesting. Refer to Child Profile Benchmark #3. |
||||||
|
COUNTY LETTERHEAD |
||||||
|
The Pennsylvania Department of Public Welfare regulations require that all children entering adoption from the foster care system have a written child profile of all the existing background information on the child, which will be necessary for the adoptive family to make a decision about accepting the child into their home, and eventually, in parenting the child and meeting his/her needs.
The ________________________ (County children & youth agency name) has a contract with ________________________ (affiliate name) to conduct child assessments on behalf of children in our care and custody for whom adoption planning is the goal ordered by the Juvenile Court. We, therefore, authorize the release of information on _________________________ (child's name) to ________________________ (affiliate name) who is providing this service on behalf of our agency, in order to assure the future safety and well being of this child in his/her adoptive family. Such information needed includes, but is not limited to, birth records, child abuse history, medical records, educational records, psychological evaluations, developmental assessments, etc. | ||||||
|
Should you have specific questions regarding the information to release, please contact the below listed caseworker at our agency, who is responsible for assuring services to this child. |
||||||
|
||||||
|
This information requested should be sent to the attention of: (Affiliate contact person & address) Close window
|