Consent for Group Participation
Name: Date of Birth:
I will participate in group servicesI will not participate in group services
For groups that involve physical movement:
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: 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.
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Consent for Group Participation
Agree & Sign