Impart | SYNC

I,   Full Name of Child/Ward*      acknowledge and understand that by signing this form, I agree 1) to participate in intervention(s) under Impart's Mental Health Care arm, Strengthening Youths in a Network of Care (SYNC) Limited, and 2) subject to the terms and conditions below. 

The terms "Impart's Mental Health Care arm" and "SYNC" / "Strengthening Youths in a Network of Care" might be used interchangeably in this form.

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1. Introduction
SYNC is overseen by Raksha Kartik (raksha@impart.sg). Our Youth Advocates (all of whom are volunteers) go through intensive training and work under the supervision of skilled professionals to ensure that Impart meet relevant standards of care for the individuals who are under our care. Your participation in our programmes and services is entirely voluntary.

2. Potential Risks and Benefits
2.1 Potential Risks
Impart Ltd. and the Youth Advocate will take all reasonable steps to provide a safe and conducive environment for each participant in this program. However, Impart Ltd. assumes no responsibility whatsoever for any injury, loss, damage or harm to any participant or to his/her property, whether directly or indirectly, as a result of participation in the intervention(s), save as required by law. Impart Ltd. does not provide any medical, hospitalization or other insurance for participants in the intervention(s), nor will Impart Ltd. provide any medical treatment or compensation for any injury sustained as a result of participation in their interventions, except as required by law.

2.2 Potential Benefits
Depending on our assessment of your needs as well as your goals, you may receive various interventions. These include:
(a) Learning how to keep yourself safe (physically, emotionally, sexually) and understand the resources that are available to you;
(b) Learning coping skills, which will support you in better managing your emotions and the difficulties you may face in daily life; and
(c) Getting connected to other stakeholders and resources, that may support you better in your specific needs.

I understand the terms covered in "Potential Risks and Benefits".* 

3. Confidentiality
Any information that is obtained in this program that can be personally identified with you will remain confidential and will be disclosed only with your permission or as required by law. A client file will be created for you during your journey with us. This file is private and confidential, and is protected under the Personal Data Protection Act (Singapore). All information shared by you during the sessions is confidential and will not be revealed to any other person or agency without your permission with the following exceptions:

3.1 Duty to Warn
If you intend to take harmful, dangerous, or criminal action against another human being, or against yourself, it is SYNC's duty to warn the appropriate individuals or agencies of such intentions. In addition, any actual or suspected acts of child, elder, or disabled person abuse (including physical abuse, sexual abuse, unlawful sexual intercourse, neglect, emotional and psychological abuse) will be reported to the appropriate agencies by the organisation.

3.2 Clinical Supervision / Consultations
Information about you may be discussed in confidence, without revealing your identity, with other professionals and/or supervisors for the purpose of supervision and consultation, and providing you with the best possible service.

3.3 Resource Matching
In the case where Impart connects you with an external resource, the following information will be released to the stakeholder either through their referral processes or through a password-protected document. Impart will get your consent for the provision of any additional information required.
(a) Full Name, NRIC & Birth Date
(b) Demographics (Gender, Race, Nationality)
(c) Brief Background
(d) Impart's Needs Assessment and Interventions

I understand the terms covered in "Confidentiality".*      

4. Personal Data
4.1 Personal data which we may collect from your child/ward includes, without limitation:
(a) contact information such as their name, home or business address, email address and phone number;
(b) information relating to their identity such as their birth date, nationality, and/or passport number or identity card details;
(c) their resume, educational qualifications, professional qualifications and certifications, and employment references;
(d) their work-related health issues and disabilities;
(e) their responses to questionnaires administered within the programme; and
(f) their photographs.

4.2 The purpose of collecting such personal data is:
(a) for our legitimate business interests, including but not limited to the internal administration of our business, research studies, training and monitoring the performance of our staff and consolidating information and/or data, audit, compliance, documentation, IT security and risk management purposes, obtaining external advice on our obligations and rights etc.; and
(b) to ensure our compliance with legal obligations that we are subject to, including but not limited to our obligations to the courts and to any other legal authorities, or to consultants and professional advisors such as accountants and auditors.

There may be certain purposes / bases for collecting your data that are not specified above. If necessary, we will notify you of such other base or purpose at the time of obtaining your consent, unless the processing of your personal data without your consent is permitted under the PDPA or any other written law.

I understand the terms covered in "Personal Data".*      

5. Code of Conduct
(a) The Youth Advocate(s) and the child/ward are not allowed to consume drugs/alcohol or smoke during their interaction.
(b) The Youth Advocate(s) and the child/ward are not allowed to partake in any vices or crime during their interaction.
(c) Lending and borrowing of money between Youth Advocate(s) and the child/ward are not permissible. The Youth Advocate(s), however, can connect the child/ward to resources or financial aid.
(d) The Youth Advocate(s) is/are only allowed to meet the child/ward in public spaces and not any private spaces (e.g. private residence, hotel).

I understand the terms covered in "Code of Conduct".*      

6. Participation and Withdrawal
You can choose whether or not to allow your child/ward to be part of this program. Even after your consent, you may withdraw their participation at any time without consequences of any kind or loss of any benefits to which you are otherwise entitled.

I understand the terms covered in "Participation and Withdrawal".*      

7. Acknowledgement and Consent
The purpose and nature of Impart Mental Health Care Arm's programmes and services have been sufficiently explained and I hereby provide my consent to participate in their intervention(s). I fully understand, and agree to all terms and conditions listed above, and I understand that I have the right to withdraw my participation at any time without any penalty.

I also provide consent to Impart Ltd.* to use or disclose my personal data including, but not limited to the full name, NRIC number, and contact details for purposes of the professional services and operations of the programmes and services.

* Impart Ltd. should comply with all statutes under the Personal Data Protection Act and where the program does not, its primary objective is to ensure compliance as soon as practicable.

Full Name of Child/Ward*      
Signature of Child/Ward*   

Date*  

For child/ward under age of 21 (only if applicable):

I,    Full Name of Parent/Guardian,    Please Select Parent Guardian    of   Full Name of Child/Ward* acknowledge and understand that by signing this form I agree 1) to have my child to participate in IMNA organised by Impart Ltd's mental health arm, Strengthening Youths in a Network of Care (SYNC) Limited, and 2) to the terms and conditions above.

Signature of Parent/Guardian   

For office use:
Professional Indemnity
I have discussed and explained all the terms stated in this consent form to the client to the best of my abilities. In my professional opinion, the client appears to understand the information I have presented. This person is fully competent to give informed consent to receive professional services offered by Impart Limited's Mental Health Care arm, SYNC. 

Full Name of Main Youth Advocate* 
Signature of Main Youth Advocate*   

Full Name of Supporting Youth Advocate
Signature of Supporting Youth Advocate   

Date*