Consent for Group Participation

Center for Family Development

1258 High Street, Eugene, OR 97401 541-342-8437 / Fax 541-242-2999

Name:     Date of Birth: 

Consent for Group Participation

  • I acknowledge that I have been referred to participate in a group provided by Center for Family Development (CFD).
  • I understand that information about my participation in this group is confidential and that no information will be released to anyone outside CFD without written authorization from me.
  • 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 provided by Oregon law. Individuals in the protected category are children, elderly persons, developmentally disabled persons, or persons receiving mental health services.

For groups that involve physical 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.

I have read and understand this consent and have a received a copy. I have had the opportunity to ask questions. I acknowledge that I have been informed that CFD is legally obligated to disclose past or threatened child, elder, or developmentally disabled person abuse, or abuse of a person covered by OHP or other public funding.

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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CFD Client Forms
Signature Certificate
Document name: Consent for Group Participation
lock iconUnique Document ID: c3e734a73de888faec197bc9dabd49781cc692d2
Timestamp Audit
April 14, 2020 3:53 pm PDTConsent for Group Participation Uploaded by Jason Dooley - IP
April 29, 2020 8:41 am PDTRecords Department - added by Jason Dooley - as a CC'd Recipient Ip:
April 29, 2020 9:41 am PDTCFD Main - added by Jason Dooley - as a CC'd Recipient Ip:
May 5, 2020 9:30 am PDTCFD Main - added by Jason Dooley - as a CC'd Recipient Ip: