What should I do if I provided someone with services for domestic violence, sexual assault and/or stalking, and I receive a standard consent form (DCH-3927) from another provider that this person has signed?

If you or the agency you work for receive grant funding under the Violence Against Women Act and/or the Family Violence Prevention and Services Act, you may not honor or accept this form. You must obtain the person’s written consent on a separate form before disclosing any personally identifying or individual information about the person. This includes information about whether or not you provided services to the person.

 

 

  • Discuss concerns about the standard form with the person as described here. If a release is needed, ask the person if he or she is willing to sign a separate release for someone who has received services for domestic violence, sexual assault, and/or stalking. The National Network to End Domestic Violence has developed a sample form that meets the VAWA and FVPSA requirements (available in English and Spanish).
  • If you can do so without disclosing personally identifying or individual information about the person, you may wish to give the provider who sent you the standard consent form general information about the federal restrictions that you must follow regarding consent forms.

If you or the agency you work for do NOT receive federal funding under the Violence Against Women Act or the Family Violence Prevention and Services Act, you must honor and accept the standard form unless you are held to more stringent requirements under another federal law or regulation. However, you should discuss concerns about the standard form with the person who signed it, as described here. This will give the person an opportunity to withdraw his or her consent if it presents safety concerns. Information on withdrawal of consent is available on the DCH-3927: BEHAVIORAL HEALTH STANDARD CONSENT FORM PROVIDER AND ORGANIZATION FREQUENTLY ASKED QUESTIONS document - see question 17.