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Consent for Group Participation

1258 High Street, Eugene, OR 97401

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

Name: Date of Birth:

Consent for Group Participation

I am requesting to participate in a group provided by Center for Family Development (CFD). If I will only be participating in a group at this time, I understand that I will need to complete an assessment if I wish to later engage in other behavioral health services offered by CFD.

I understand that the information shared within the group, including identities of all group members, is confidential. I agree to hold group information confidential.

I acknowledge that if information is revealed to CFD of past or threatened abuse of a person who is in a protected category, whether that person is myself or another individual, CFD must disclose and report such information, as required by Oregon law. Individuals in the protected category are children, elderly persons, developmentally disabled persons, and persons receiving mental health services covered by OHP or other public funding.

For groups that involve movement:

I understand that all activities in this group are optional, and I agree to take full responsibility for monitoring and modifying these activities as necessary, so as not to cause injury or irritation to my body.

I release Center for Family Development from all liability for injury or discomfort to my person which may be related to my participation in this group.

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: ClientPersonal Representative, see below

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.

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July 29, 2021 7:34 pm PDT

Consent for Group Participation Uploaded by Do Not Reply - donotreply@c-f-d.org IP 65.157.96.202

August 2, 2021 8:42 am PDT

CFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 65.157.96.202