Connections – An I/DD Wellness Group Registration & Informed Consent for Participation

Connections – An I/DD Wellness Group Registration & Informed Consent for Participation
Youth Age/Guardianship Status*

Youth is Under 18.Youth is 18 or older & is own guardianYouth is 18 or older & is NOT their own guardian

Demographic Information
1. Youth Name*
Youth's Pronouns*
3. Youth Age*
Contact Information

Please include contact information below for the Parent/Guardian if youth is under 18 or is not their own guardian)
Parent/Guardian Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Youth or Parent/Guardian Email*
example@example.com
Youth or Parent/Guardian Phone Number*
Emergency Contact Name:*
Emergency Contact Phone Number*
Please enter a valid phone number.

Confidentiality Statement
We will treat what is told to us with great care. Our professional code of ethics (that is, our profession’s rules about values and moral matters as described by American Psychiatric Association) and the laws of this state prevent us from telling anyone else what group members tell us unless they give us written permission. These rules and laws are the ways our society recognizes and supports the privacy of what we talk about—in other words, the “confidentiality” of therapy including group support. However, we cannot promise that everything group members tell us will never be revealed to someone else. There are some times when the law requires us to tell things to others. There are also some other limits on our confidentiality. We need to discuss these, because we want you to understand clearly what we can and cannot keep confidential. Our group members need to know about these rules now, so that they don’t tell us something as a “secret” that we cannot keep secret. So please read these pages carefully and keep a copy. At the first group meeting, we can discuss any questions you might have.

When you or other persons are in physical danger, the law requires us to tell others about it.

Specifically:

a. If we come to believe that you are threatening serious harm to another person, we are required to try to protect that person. We may have to tell the person and the police, or perhaps refer you for psychiatric screening.

b. If you seriously threaten or act in a way that is very likely to harm yourself, we may refer you for psychiatric screening, or to call on your family members or others who can help protect you. If such a situation does come up, we will fully discuss the situation with you before we do anything, unless there is a very strong reason not to.

c. In an emergency where your life or health is in danger, and we cannot get your consent, we may give another professional some information to protect your life. We will try to get your permission first, and we will discuss this with you as soon as possible afterwards.

d. If we believe or suspect that you (or another minor or elderly person) are being abused. We must report this to the NJ Abuse to further investigate.
Other Limits to Confidentiality
A safe environment is created and maintained by the group facilitator and its members. Although we are bound by confidentiality as stated above as group members you are bound by honor to maintain the confidentiality of your peers. We ask that you do not discuss the group, its members or what is said in the group with others. We realize you may want to talk about the work you are doing or other significant ways the group has impacted your life. This is fine, but please remember to not compromise the confidentiality of other group members in the process.
General Group Rules
1. Respect other members of the group

2. Respect yourself

3. Respect the process: Arrive on time and stay the full time. Make a commitment to attend each week. Parents/Caregivers are expected to attend all Caregiver Sessions, in addition to the youth participant attending all virtual and in-person sessions/trips.

4. Confidentiality: this is very important! The group environment needs to feel safe for everyone. It is vital that you keep what is said in the group confidential. Do not discuss other members with anyone outside of the group (this includes other group members Facilitators cannot enforce confidentiality although we strongly encourage it.
AGREEMENT
I agree to attend the group. After reading this form, I understand that I am free to discuss any concerns or questions with a group leader. I understand the group is not treatment related; rather it intends to provide psychoeducation.
Youth Signature (or indication if unable to sign)*

Clear
The purpose of the group is to provide education and support. I understand these groups are not treatment related; rather provide psychoeducation. I understand that my child may receive information, education and support. I understand the nature of this group is a closed group, meaning participants will be capped at 14 individuals and are expected to attend all sessions. Should, for any reason, a participant opts to no longer participate, waitlisted individuals will be offered an opportunity to join. I agree to contact Victoria Azzopardi, LCSW at 732-202-1585 x117 if I have any questions, concerns, or disagreement with the group’s focus or material.
Parent/Guardian Signature*

Clear
Video Conferencing
I hereby consent to my child's participation in video conferencing with the indicated Ocean Partnership for Children Group. I understand the following with respect to video conferencing:

1. I understand that I have the right to withdraw consent at any time without affecting my right or my child’s right to future care, services, or program benefits to which I would otherwise be entitled.

2. I understand that there are risk and consequences associated with video conferencing, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.

3. I understand that there will be no recording of any of the online sessions by either party. All information disclosed within sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.

4. I understand that the privacy laws that protect the confidentiality of my child’s protected health information(PHI) also apply to video conferencing unless an exception to confidentiality applies (i.e. mandatory reporting of child, elder, or vulnerable adult abuse; danger to self or others

Additional Items
- CONSENT FOR EMERGENCY MEDICAL TREATMENT: In the event that my child is the victim of an accident, injury or illness while on outings with an Ocean Partnership for Children, Inc. employee and I am unable to be reached I authorize the Care Manager or the Care Manager’s designee to take action and give consent on my behalf as his or her judgment dictates.
- CONSENT FOR PARTICIPATION IN SUPERVISED SPORTS & RECREATIONAL ACTIVITIES: I give my consent for my child/children to participate in supervised sports and recreational activities that are scheduled as part of the program, which may be outside of the home and may require transportation outside of Ocean County. I understand and acknowledge that some of the activities may involve unanticipated risks and could result in injury to the child, to property or to third parties. I agree to accept and assume all of the risks involved in activities within and outside of my home. Transportation for activities may be furnished by Ocean Partnership For Children, Inc.
- CONSENT/WAIVER OF RESPONSIBILITY FOR PERSONAL INJURY: I give my consent for my children to possess certain items of personal property. I understand that Ocean Partnership For Children, Inc. is not responsible for the loss, theft, or damage of personal property or money.
- CONSENT FOR TRANSPORTATION: I hereby give my consent for my child/children to be transported by Ocean Partnership For Children, Inc., as needed.
- CONSENT FOR INFORMATION TO BE USED IN RESEARCH: I give my consent for the evaluation of data obtained during my enrollment in Ocean Partnership For Children, Inc. for research to evaluate effectiveness of the program. I understand that this research may be presented at conferences, universities, and in publication. I understand that information collected for this research is part of the usual Ocean Partnership For Children, Inc. evaluation procedures. I understand that my family’s confidentiality will be protected. No information that is presented to the public will contain any identifying information such as name, pictures, address, or telephone number.
*

By Checking this box and signing my name below, I certify that I have read the information provided above. I understand the information contained in this form and all of my questions have been answered to my satisfaction.
The signatures here show that the youth attending the group has read, discussed, understand, and agree to abide by the points presented above.
Youth Signature (Or indication if unable to sign)*

Clear
The signatures here show that the parent/guardian of the youth attending the group has read, discussed, understand, and agree to abide by the points presented above.
Parent/Guardian Signature*

Clear

Youth Information
So that facilitators can best prepare to ensure the registered youth receives the utmost attention and care throughout the program, please complete the following questions. Please note, lead facilitators will be calling prior to start of group for clarification and assessment of needs.
1. What are the youth's areas of strengths, interests, and common coping skills when upset?*
2. Does the youth have any limitations or barriers to learning/communicating that we should be aware of? i.e. physical impairments, daily living skills challenges such as toileting, handwashing, etc.*
3. How does the youth communicate? Does the youth use any assistive technology, and if so, will there be access to it during the course of the group sessions?*
4. What are the youth's common triggers we should be aware of? How does the youth react when they are triggered and what helps to calm them down?*
5. Please list any dietary restrictions or allergies.*
6. Is there any other information you would like facilitators to know?*
Thank you and we look forward to this journey with you!

The mission of Ocean Partnership for Children, Inc. is to enhance the well-being of children & their families through natural & community-based supports
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Connections – An I/DD Wellness Group Registration & Informed Consent for Participation

Demographic Information

Confidentiality Statement

Other Limits to Confidentiality

General Group Rules

AGREEMENT

Video Conferencing

Youth Information