Instructions for the ReST Authorization-Consent to Release Information

This form should be filled out by the agency that refers the individual/client to the Resource and Stabilization Team(ReST). No records will be requested by the signing of this consent/release of information form. You can hover over certain sections for more information regarding the completion and information needed.  Other instructions for any check boxes can be found below.  Please make a copy for the client after all information is filled in.  If you have any questions, please contact the ReST Coordinator, Sarah Kennedy at 970-328-2607, or sarah.kennedy@eaglecounty.us

There are two ways to submit this form and refer a client/patient case to the ReST:

1)      Fill in all required information (*) and as much additional information as you can.  Click the PRINT icon at the bottom of the form and have the client/patient sign and date the bottom of the form.  Fax the form to the ReST Coordinator at 855-848-8829.

2)      Fill in all required information (*) and as much additional information as you can.  Have the client/patient digitally sign their name by asking them to “click to sign” and entering their information.  The client/patient must complete this step on their own.  3rd parties completing the digital signature would be committing signature fraud.  Once they have digitally signed their name click the SUBMIT icon at the bottom of the page.  The completed form will be emailed to the ReST Coordinator.

Further information on how to fill out each check box section of this form:

This is an: Initial request, if this is the first contact you have had with the client.  The ReST asks that you send in another referral with the box -  Revocation/Withdrawal of Prior Request – checked if a client/patient changes their mind about allowing the ReST to discuss their case or  no longer wants to be seen by the Community Health Worker.

Has the Client/Patient been seen by or made contact with any other agencies: This is any agency that the individual has been in contact in the past. This is self-reported by individual.