Application Referral Form

Consent to Exchange Information

All questions are required, unless otherwise noted

I understand that different agencies provide different services and benefits. Each agency must have specific information in order to provide services and benefits. By completing and submitting this form, I am allowing agencies to exchange certain information so it will be easier for them to work together effectively to provide or coordinate these services or benefits.

I, ,
am authorizing this form for
full printed name of client
I want the following confidential information about the Client (except drug or alcohol abuse diagnosis or treatment information) to be exchanged

I want:

Cabaniss Homes or designee, 
3723 Old Forest Road, Suite H, Lynchburg VA 24501

Check all that apply

I can withdraw this consent at any time by telling the referring agency. This will stop the listed agencies from sharing information after they know my consent has been withdrawn. I have the right to know what information about me has been shared, and why, when, and with whom it was shared. If I ask, each agency will show me this information. I want all the agencies to accept a copy of this form as a valid consent to share information. If I do not authorize this form, information will not be shared and I will have to contact each agency individually to give them information about me that they need.

Consenting person or persons