I hereby authorize ___________________________, Office of the Public Defender, ______________________________________, _________________________ or any person or persons duly authorized by him/her to:

Verify all financial information pertaining to me with employers, banks, credit unions, loan companies or any other source. Obtain all necessary medical information, evaluations, or memoranda from doctors, psychologists, social workers, clinics and hospitals concerning my and my child’s examinations, diagnosis, treatment or hospitalization. Obtain information from any school, counseling, labor department, welfare or other agency that has rendered its services to me or my child.

I hereby authorize all proper officials of all such organizations to _________________________, his/her employees or any persons duly authorized by him/her, such requested information for one year from this date for use in regard to legal proceedings. I understand the information disclosed may be from records whose confidentiality is protected by state and/or federal law and may contain information pertaining to psychiatric, HIV/AIDS, drug and/or alcohol diagnosis and treatment and that this authorization may be revoked by me at any time except to the extent that action has been taken in compliance with this request.

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Child/Witness Signature Parent/Guardian Signature

DOB: ________________________

Client: ______________________________

Date: ______________________________