Consent for BSS Services

1258 High Street, Eugene, OR 97401

Phone 541-342-8437 | Fax 541-242-2999

Name:     Date:

Consent for Services - Behavioral Support Specialist (QMHA)

This document is an addendum to the Consent for Services.


  • As part of my request for services with Center for Family Development (CFD), I authorize clinical staff to provide Behavioral Support Specialist (BSS) services.
  • I may ask questions at any time.
  • I understand that the BSS assigned is not a therapist, and concerns regarding the well-being of family members are to be discussed with the therapist.
  • My request for services from CFD is voluntary and I may discontinue at any time.

Treatment for Adolescents

  • If I am an adolescent age 14 or older, I have the right to access services without consent from my parent/guardian.
  • My parent/guardian will be involved before the end of services unless they refuse or there are clear clinical reasons not to involve them, which will be documented in my record.

Risks and Benefits

  • There may be periods during services that may result in emotional discomfort, changes in relationships, and temporary worsening of symptoms. The goal and intended benefit of services and supports is the resolution of the presenting problem.
  • I understand that the possibility of physical injury exists during participation in many recreational events.
  • I give permission for my child to participate in the activities indicates below with their BSS on an ongoing basis.

If other, please describe:  


  • I give permission for the BSS to provide transportation in their personal vehicle when necessary.
  • I and my child agree to follow the safe practice guidelines outlined in Oregon's Occupant Protection Law regarding car seats, booster seats, and/or safety belt systems.


  • The BSS is supervised by a Clinical Supervisor.
  • I may access the therapist and BSS's immediate supervisor upon request should I experience concerns or wish to express a grievance.
  • I understand that the BSS assigned will maintain a confidential relationship within the supervisory process.

Mandatory Reporting

  • I understand that if my child should report engaging in, or threatening to engage in, any life-threatening activities, the parent/guardian would be notified as soon as is practicable. I further understand that the BSS will not use physical force, or physical means to restrain, except in immediate life-threatening situations.
  • I understand that if my child leaves during an interaction with a BSS, they may not be stopped and that the parent/guardian will be notified of their departure as soon as reasonably practicable.
  • If, during services, I and/or my child reveal to the BSS past or threatened abuse of a person who is in a protected category, whether that person is ourselves or another individual, the BSS must disclose and report such information as required by Oregon law. Individuals in the protected categories are children, elderly persons, developmentally disabled persons, and persons receiving mental health services covered by Oregon Health Plan or other public funding.
  • If my child threatens to harm themselves or others, CFD is required to intervene, which may include a report to the appropriate agency and/or authority.
  • In the event of threatened harm to any individual, the BSS may warn the intended victim(s) by the most efficient means available.

Release of Information

  • The BSS may share information disclosed by the child with the parent/guardian, therapist, and clinical supervisor.
  • The BSS works collaboratively with a therapeutic team which includes my child, the parent/guardian, therapist, and psychiatric services provider (if applicable), to address behavioral health needs.
  • In cases of medical emergency, CFD may access emergency medical treatment on my child's behalf. Information may be released to the attending emergency workers and will be limited to only information that is necessary to resolve the situation. Any information shared will be documented in my child's record.
  • If an additional child (e.g., friend or relative) is to accompany the BSS and my child for a session, written permission will need to be obtained in advance from the parent/guardian of the additional child.
  • If a child abuse investigation is being conducted, CFD is required under Oregon law to permit the investigating agency to inspect and copy records of the child involved in the investigation without the consent of the child or the parent/guardian of the child.

Scheduling and Cancellations

  • I agree to keep scheduled appointments with the BSS.
  • I will provide at least 24 hours advance notice if we need to cancel an appointment.
  • I understand if my child misses multiple appointments, BSS services may be discontinued.

General Information

The BSS can:

  • Notice and reinforce positive behaviors.
  • Reinforce the process of learning/practicing/utilizing new skills.
  • Identify and build on strengths and talents.
  • Engage with children in positive social activities.
  • Offer suggestions to children in a manner that decreases the likelihood of resistance.
  • Act as part of a therapeutic team.
  • Model healthy social behaviors and boundaries.
  • Follow expectations and limits set by parent/guardian, therapist, and clinical supervisor.

The BSS does not:

  • Punish or act as an "agent of control."
  • "Make" children do things (e.g., do homework, clean their room, talk about what they've done wrong). They are, however, very good at being available to help.
  • Give advice to caregivers.
  • Play violent video games or watch violent movies with my child.
  • Purchase gifts for my child. The BSS is provided with a small amount of money to facilitate activities.

CFD provides services to all individuals who are eligible regardless of race, ethnicity, gender, gender identity, gender expression, sexual orientation, religion, creed, national origin, age (except when program eligibility is restricted to children, adults, or older adults), familial status, marital status, source of income, and disability.

My signature affirms that I have read and understand this form and have had the opportunity to ask questions.

This document is being signed by:

If you are signing as the Personal Representative, please complete the following section; otherwise, proceed to signing the form.

Full legal name of Personal Representative:

Relationship to client:

Definition of Personal Representative:
For Adults: A person with legal authority to make healthcare decisions on behalf of the adult. Supporting documentation required.
For Youth: A parent, guardian, or other person acting in the place of a parent with legal authority to make healthcare decisions on behalf of the minor child. Supporting documentation may be required.

Leave this empty:

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Signature Certificate
Document name: Consent for BSS Services
lock iconUnique Document ID: a8733c36324d95bc28bd3cc0bc79b64794147fe7
Timestamp Audit
July 18, 2023 1:38 pm PDTConsent for BSS Services Uploaded by Do Not Reply - IP
July 18, 2023 2:05 pm PDTCFD Main - added by Do Not Reply - as a CC'd Recipient Ip:
July 28, 2023 10:39 am PDTCFD Main - added by Do Not Reply - as a CC'd Recipient Ip:
April 9, 2024 10:51 am PDTCFD Main - added by Do Not Reply - as a CC'd Recipient Ip: