1258 High Street, Eugene, OR 97401
Phone 541-342-8437 | Fax 541-242-2999
Name: Date of Birth:
Entry
• As part of my request for services with Center for Family Development (CFD), I authorize clinical staff to provide low barrier services through the Link program.
• I may ask questions at any time.
• My request for Link services from CFD is voluntary and I may discontinue at any time.
Link Services Include (but are not limited to):
• Case management (help getting connected to services and other community resources)
• Peer support from people who have personally faced similar challenges and can offer understanding and guidance.
Link Program Service Exceptions
• Link program staff do not provide clinical assessment, diagnosis, or treatment.
• Clinical services require separate enrollment and consent.
Transportation
• I give permission for program staff to provide transportation in their personal vehicle when necessary.
• I agree to follow the safe practice guidelines outlined in Oregon's Occupant Protection Law regarding safety belt systems.
• I understand that transportation will only be provided to me as the client.
• I understand that transportation will not be provided if I am visibly under the influence of substances.
Supervision
• Program staff are supervised by a Clinical Supervisor.
• I may access the program supervisor upon request should I experience concerns or wish to express grievance.
• I understand that program staff will maintain a confidential relationship within the supervisory process.
Release of Information
• I understand that no information about me will be released to entities not involved in my care without my written authorization, except as described below.
• In cases of medical emergency, CFD may access emergency medical treatment on my 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 record.
Mandatory Reporting
• If information is revealed to CFD of past or threatened abuse of a person who is in a protected category, whether that person is me 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.
• If I threaten to harm myself 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, CFD may warn the intended victim(s) by the most efficient means available.
• 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.
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 had the opportunity to have my questions addressed.
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.
