Logo

Consent to Participate

What is Community Partners for Child Safety (CPCS)?
The service will provide home based case management services to connect families to resources within the community to strengthen the family. Community resources are included, but not limited to schools, social service agencies, health care providers, public health, hospitals, childcare providers, community mental health agencies, Healthy Families and Twelve Step Programs. In general, each community defines its own resources. This is a no cost, voluntary service.
How your data is kept confidential:
  • Information is shared only on a need-to-know basis with appropriate staff, consultants, and other professionalswithin the CPCS program
  • The information you provide will be stored in a secure database
  • Staff and their supervisors can only access data regarding families to which they are assigned
  • Your information may be shared with funders, evaluators or researchers
  • Any reports and evaluations given to funders are combined data
  • No individual family is ever identified in data given to evaluators
  • Data sent to the State of Indiana for purposes of billing and evaluation are encrypted
Confidentiality:
  • If we have reason to believe any child is being abused or neglected, we are required by law to report to theIndiana Department of Child Services
  • We must disclose information if ordered by a court
  • Your data may also be used to match Indiana’s child abuse and neglect data system to determine the impact ofCommunity Partners for Child Safety outcomes
    • Such reports are only provided in a combined format that provides no information that directly identifiesyour family
  • Your data may also be used to match data at the Indiana Department of Health to determine how CPCS servicesare impacting health outcomes
    • Reports stemming from such data matching are used to improve CPCS service systems. Data involved inthese data matches are combined in a format that provides no information that directly identifies you oryour family.
By signing below, I am voluntarily consenting to participate in CPCS services as described in this form. I am confirming I have read (or it has been read to me) and understand all the information above regarding confidentiality.
I am also confirming I have had the opportunity to ask any questions I may have pertaining to this form and its contents, and any questions have been answered to my satisfaction.
Refusal to sign may impact your ability to receive services.

Clear Signature
Clear Signature
Clear Signature
Client Signature
Client Signature
Staff Signature