Consent for Assessment
Healthy Families of Sullivan
Family Assessment Consent Form
Date of Assessment_________________
I, (we), __________________________________________________________,
agree to participate in the family assessment.,
I/We understand that the family assessment is designed to determine the
resources, priorities and concerns of my/our family related to the enhancement of my/our
child’s health and development.
I/We understand that all information obtained during the family assessment will
remain confidential and will only be shared with appropriate Healthy Beginnings staff for
the purpose of referral.
I/We give __________________________permission to document the family
assessment.
_______________________________________________
Parent Signature
______________________
Date
_______________________________________________
Parent Signature
______________________
Date
I
Consent for Assessment
Healthy Families Oneida County
Family Rights
Healthy Families shall ensure that the following policies and procedures are provided so
that a family’s rights are protected in accordance with federal, state, and agency
requirements:
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The right to services that respect your personal liberty.
The right to refuse services.
The right to a written, individualized family support plan based on your family’s needs
that you will develop with the family support worker shortly after beginning services
with Healthy Families.
The right to periodic review and re-assessment of family needs and appropriate
revisions of the plan.
The right to ongoing participation in the planning of services to be provided and in
the development and periodic revision of the individualized family support plan.
The right to referral, as appropriate, to other providers’ services at any time, including
upon discharge from the program.
The right to confidentiality of records.
The right to access, upon request, one’s own records.
Confidentiality Policy
How do we keep your information confidential?
 Records are kept in a locked file.
 Records cannot be removed from office areas unless they are signed out for a
specific purpose.
 Information is shared only on a need-to-know basis with appropriate staff,
consultants, and other professionals.
Who can see your records?
 Appropriate staff members of Healthy Families.
 Consultants on a need-to-know basis.
 You can see your own records, but not those of others.
How do we use your confidential information?
 To assess the needs of you and your child(ren) in areas of health, social services
and education or training.
 To make reports to our funders (your name is never used).
 To work cooperatively on your behalf with other agencies. You will sign consent
forms to allow this exchange of information with health professionals, consultants,
etc.
Are there times when we would share information about you without your
permission?
Only if we think somebody is or may be hurt…
 If we have reason to believe any child is being abused or neglected, we are required
to refer it to the New York State Central Registry in Albany, NY.
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Such reports are made so families will receive the assistance they need to help keep
their children healthy and safe.
Photographs and Videotapes
When working with families, it has been our experience that taking pictures and
recording families on film is a beneficial way for families and workers to see themselves
and learn from one another. If you are willing to have a family support worker record
your family on film, we want you to understand how it would be used: (1) For you and
your family support worker to watch together and talk about; (2) For your worker and her
supervisor to view and discuss; (3) For workshops involving other human service
workers who are learning to increase their skills in working with families. If you agree to
allow filming of your family you may agree to one or all three of the uses outlined above.
Consent and Authorization
I, ___________________________________________________________, am
interested in having a Healthy Families Family Support Worker Provide services to my
family. I understand that this person will provide me with assistance as needed to the
best of his/her ability.
I give permission for the Family Support Worker to share pertinent information with other
agency personnel involved in supporting my family and to refer for outside services and
assistance when necessary.
I give permission to Healthy Families to send a written report to the agency that
requested service, regarding the outcome of their request. Permission is given to
Healthy Families to release information concerning myself and my family to the belownamed agencies and individuals. This consent will also authorize the named agencies
and individuals to release information to Healthy Families.
OB/GYN
__________________________________________________
Pediatrician
__________________________________________________
Other
__________________________________________________
__________________________________________________
I authorize Healthy Families to record ________________________________________
using audio-visual equipment. Recordings may be used as described in the
Photographs and Videotapes section above in numbers (1) _____ (2) _____ (3) _____.
When I sign this authorization I am agreeing to not bring any suit for liability against
Healthy Families Oneida County when these recordings are used in the ways I have
checked.
I release Healthy Families Oneida County and its employees from liability connected
with transporting in an agency or personal vehicle.
This consent is to remain in effect for the duration of services. This authorization ends at
the time my involvement in the Healthy Families program ends. I may consult with the
agency at any time if questions arise regarding this consent. This consent and
authorization may be withdrawn upon my written request, as of the date of receipt by
Healthy Families.
Signed __________________________________________________
_______________
Date
Signed __________________________________________________
_______________
Date
FSW ____________________________________________________
_______________
Date
Consent for assessment
Healthy Families-
Oneida County
FAMILY NURTURING CENTER OF CNY, Inc.
209 Elizabeth Street-4TH Fl.
Utica, N.Y., 13501
315-738-9773
Consent Form
Healthy Families-Oneida County is part of a national support program for
expectant and new parents. We/I agree to participate in a meeting with the
Family Resource Educator. We/I understand that this meeting is designed to
determine resources, priorities, and concerns for our/my family as they relate
to our/my child’s health and development.
We/I give ___________________________________
permission to
Family Resource Educator
meet with us/me and to document what is shared.
We/I understand that all information obtained during the meeting will
remain confidential and will be shared with appropriate Healthy Families
program staff for the purpose of referral. At the end of the meeting with the
Family Resource Educator, we/I will be provided information, referrals, and
child development information, based upon my family’s concerns and needs.
Our/my information may also be shared with non-Healthy Families staff for
the purpose of referral to other agencies/programs that the Family Resource
Educator and we/I decide are appropriate.
Date: _______________________
_____________________________
Parent’s Signature(s)
Consent for assessment
_____________________________
Consent for Assessment
Healthy Families Ontario
Family Assessment Interview Consent
I/We agree to participate in the family assessment interview. I/We understand
that the family assessment interview is designed to determine resources,
priorities and concerns of my/our family as they relate to the enhancement of
my/our child's health and development.
I/We understand that all information obtained during the family assessment will
remain confidential and will be shared only with appropriate Healthy Families,
Ontario staff.
I/We understand that the referral source may be advised of whether or not I/we
become an active participant in the program.
I/We give the below named Healthy Families, Ontario Family Resource Educator
permission to conduct and document this family assessment interview.
________________________________________________ ______________
Parent/Guardian of Baby
Date
_______________________________________________ ______________
Parent/Guardian of Baby
Date
_______________________________________________ _____________
Family Resource Educ