Consent for Services - PSS Services

1258 High Street, Eugene, OR 97401

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

Name:     Date of Birth:

Consent for Services - Peer Support Specialist Services
This document is an addendum to the Consent for Services.


  • As part of my request for services with Center for Family Development (CFD), I authorize clinical staff to provide Peer Support Specialist (PSS) services.
  • I may ask questions at any time.
  • I understand that the PSS assigned to me is not a therapist.
  • My request for PSS services from CFD is voluntary and I may discontinue at any time.

Risks & Benefits

  • There may be periods during services that may result in emotional discomfort, changes in relationships and temporary worsening of symptoms. The goal and intended benefit of services and supports is the resolution of the presenting problem.


  • I give permission for my PSS 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 car seats, booster seats, and/or safety belt systems.

PSS Group Activities and Events

  • CFD at times provides peer activities and events where other individuals receiving services from CFD are also present. Should I choose to attend such activities and events, I understand that the information shared within them, including identities of all participants present, is confidential. I agree to hold information shared by participants, including their identities, confidential.


  • My PSS is supervised by a Clinical Supervisor.
  • I may access my PSS's immediate supervisor upon my request should I experience concerns or wish to express a grievance.
  • I understand that the PSS assigned will maintain a confidential relationship within the supervisory process.

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.

Release of Information

  • I understand that the possibility of physical injury exists during participation in many recreational events.
  • 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 but will be limited to only information that is necessary to resolve the situation. Any information shared will be documented in my record.
  • 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.

Scheduling and Cancellations

  • I agree to keep scheduled appointments with my PSS.
  • I will provide at least 24 hours advance notice if I need to cancel an appointment.
  • I understand if I miss multiple appointments, PSS services may discontinue.

General Information

My PSS can:

  • Discuss issues informally and provide emotional support.
  • Help me envision recovery.
  • Support me in self-determination.
  • Identify and build on my strengths and talents.
  • Support my skills in coping with or reducing mental health problems.
  • Help me and my family develop a plan for crisis.
  • Teach independent living skills.
  • Help people learn how to speak up in their own voice.
  • Link me and my family with appropriate community resources

My PSS doesn't:

  • Provide therapy or "expert" mental health care based on professional training.
  • Make decisions for me. 
  • Provide personal services like house cleaning, laundry, or transportation. A PSS may sometimes do some of these activities with you or take you somewhere in a car if he or she has a car, but the point of the meeting will always be to help you find ways to get going with these activities on your own.
  • Stay around forever. My PSS is paid to help me during a time period when I need extra support or when I am having trouble finding support for myself. My PSS seeks to help me find my own friends and community connections so that eventually, I will no longer require PSS services.

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 have had the opportunity to ask questions.

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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Signature Certificate
Document name: Consent for Services - PSS Services
lock iconUnique Document ID: e33ebebbeedecb857ab0d7d007e7092579211a1b
Timestamp Audit
November 7, 2022 9:25 am PDTConsent for Services - PSS Services Uploaded by Do Not Reply - IP