I hereby consent to be assessed for Community Partners for Safe Families through a
conversational interview and discussion of services. I understand that participation in the
Community Partners program is voluntary and that this consent may be revoked at any time.
The information gathered will include childhood history, stressors, family safety, access to
resources and health care, as well as other areas to help determine needs. Assessment tools may be
completed as required by the funding source to help determine needs and assist in program
evaluation.
All information is confidential and will be stored in a statewide database, accessible by agency
management, staff, and funders. This program is funded by the Department of Child Services.
Information will only be viewed on a “need to know” basis and will not be released to external
sources. General information on trends and program outcomes will be shared with evaluators, but
external sources will not have access to specific information without a release.
Community Partners is obligated to share information without a participant’s consent if required
by law, including suspected child abuse and/or neglect.
Interviews may be observed by management for quality.
Signatures below allow for further contact to complete the enrollment process and/or offer other
supportive services requested by my/our family.