I agree and consent to services ordered to and provided by Iris Family Support Center.
I understand that I am consenting and agreeing to only those services that the above provider is
qualified to provide within:
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The scope of degree, license, certification and/or training
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The scope of degree, license, certification and/or training of the providers directly
supervising the services provided.
I understand and authorize information collected as part of these services to be released to the
referral source.
I understand that this will include any information regarding family functioning, mental health,
substance use, child safety or other areas related to
my services.
I understand the details of participation in services will be confidential unless I authorize
the release of information to other individuals or
agencies beyond those detailed above.
Limits concerning the confidentiality of services offered and provided are:
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We may disclose confidential information when we judge that there is a strong possibility of
serious harm being inflicted by you on
another person and/or on yourself.
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Should you disclose information relating to probably child abuse, elder abuse, or abuse of a
vulnerable adult (for example, someone who is
developmentally disabled or mentally ill, or who has a disabling illness), we may be
required to notify state authorities.
Also, should you be over the age of 18 and engaging in sexual activities with someone under
the age of 18.