Family Tree Counseling Program
You are receiving services from CCD Counseling PA (CCD) or an individual or organization that is a subcontractor for CCD. CCD administers the Family Tree Program for Denton and Dallas Counties. Those services are funded by the state of Texas and are provided free of charge to you. A CCD employee, the Family Tree Case Manager enters information about you and the services you receive into an electronic database maintained by the State of Texas.
Authorization for Release of Confidential Information
I hereby authorize CCD (including any subcontractor) to disclose any and all records and information concerning myself and/or my family’s participation in the Family Tree program to the state funded Family and Youth Success (FAYS) program.
The disclosure of information authorized herein is made for the following purposes:
1. For the billing and reporting of service delivery by CCD and/or their sub-contractors
2. For the management and administration of FAYS services by the state, and,
3. To evaluate and maintain the quality services delivered to me and or my family.
In addition, I consent for a staff member at CCD to communicate with me by mail, email and by phone at the contact numbers and addresses I provide. I understand that information may be conveyed electronically and the privacy of those various communication methods cannot be guaranteed.
I understand that my records are protected under state and federal regulations and cannot be disclosed without my written consent, at any time, except to the extent that action has been taken in reliance to it. I further understand that because of these laws, neither CCD or a CCD subcontractor can provide FAYS services to me or my family without this authorization. I also understand that this authorization is voluntary, and that other options are available to me. Other options include refusal of services, seeking alternative services, electing to fund my own services, and/or seeking services that have a different source of funding.