CONSENT TO RELEASE/EXCHANGE INFORMATION – ADULT SERVICES

Name of Person Served:

This consent authorizes that Swan Community Services (SCS) may receive the information checked
below for the above individual. Furthermore, it authorizes Swan Community Services to exchange and
report information pertaining to the below marked categories.

By signing this form, I consent to receive services from Swan Community Services. Information disclosed
shall be used only for the purposes of planning and coordinating of services.

Type of Information
Ok to Do Not
Release Release
Client/CLBC Profile
Financial Aid/CLBC Funding
Employment History/Vocational Profile
Person Centered Plan (PSP)
Goals/Progress
Health Care Plan
Medications
Medical Needs/ Medical Practitioners
Evaluations: Psychological, Previous Assessment Reports
Home to Hospital
Protocols/Activity Support Guidelines
Behavioural Support/Safety Plans
Risk Assessments
Other: Specify
Personal information is protected by the BC Personal Information Protection Act (PIPA)

I understand that this information will only be used for Swan Community Services and our personnel to
better support myself. Swan Community Services will not use this information unless it is required for us
to do so in regards to your care. I understand it is my right to limit what I disclosed, and I understand
that at any time I may cancel this release/exchange of information, except to the extent that action has
already been taken. All information shall remain confidential.

THIS CONSENT IS VALID FOR 12 MONTHS FROM THE DATE SIGNED BELOW

DESCRIPTION NAME SIGNATURE DATE

Individual
Legal Representative
(if applicable)
SCS Representative

Developed: 01/2010 rev.01/2012, rev.01/16/23

RE: policy and procedure: Persons Served/Release of Information