Authorization to Refer and Disclose Information to Healthy Families/Thriving Communities Collaboratives

**Si usted no entiende el idioma Inglés, favor de pedir esta forma en Español**.

This Authorization form is used by Child and Family Services Agency (CFSA) staff to authorize the referral of a client to a Healthy Families Thriving Community Collaborative (Collaborative) for services. It also permits CFSA to provide non-health related information about the client to the Collaborative.