*A separate Consent for Exchange of Information form must be completed for each individual or agency you wish for MNTC to communicate with. *

• I understand that my records are protected by data practice laws and cannot be released without my consent unless otherwise allowed by law.
• I understand that only the information and records indicated below will be released or obtained.
• I understand that this consent does not authorize the recipient of the information or records to re-disclose the information or records to any other person or facility unless authorized by law.
• I understand that the information will only be used for the purposes indicated below.
• I understand that I may withdraw or modify this consent at any time but that the revocation or modification will not affect any release of information that previously occurred.
• I understand that this consent expires and is no longer valid one year from the date it was signed.
• I understand that observation and/or assessment can take place in either setting.

To obtain records from or release records to: