Sees-the-Day, Inc. Consent for the Release of Confidential Information from Other Treatment Facility
I, _______________________________ authorize Sees-the-Day, Inc. to disclose to ________________________________________ the following information:
_____	Psycho-Social
_____	Treatment Plan
_____	Attendance, progress, cooperatives in treatment
_____	Discharge summary/aftercare plan
_____	Other _______________________________
For the purpose of:
_____	Determination of treatment needs
_____	Continuity of care
_____	Coordination of services
_____	Compliance with probation/parole regulations
_____	Obtaining assessment/evaluation information
_____	Other _______________________________
I understand that my records are protected under the Federal Confidentiality regulations and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time. This consent automatically expires three months following discharge from treatment.
Specification of the date, event, or condition upon which this consent expires:
______________	_____________________________
Date	Resident
______________	_____________________________
Date	Witness