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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 will participate in group servicesI will not participate in group services

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: 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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Timestamp

Audit

April 14, 2020 3:53 pm PST

Consent for Group Participation Uploaded by Jason Dooley - jdooley@c-f-d.org IP 65.157.96.202

April 29, 2020 8:41 am PST

Records Department - records@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 71.238.126.129

April 29, 2020 9:41 am PST

CFD Main - main@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 71.238.126.129

May 5, 2020 9:30 am PST

CFD Main - main@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 173.8.200.225

June 24, 2020 10:30 am PST

CFD Main - main@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 65.157.96.202