Authorization / Consent Form

Authorization / Consent for Referral to Fatherhood Program
Referred By*

Referred From CIRReferred from Healthy StartI am referring myselfReferred from another program
Please Read Paragraph below to Father when obtaining Verbal Consent
Broward Healthy Start Coalition offers a Fatherhood program (T.E.A.M. Dad). The program includes several services that would allow Dad to help with his child’s development and give him access to classes that provide financial education, parenting information and much more. We would appreciate the chance to speak with you more about T.E.A.M. Dad.

I, (printed name), hereby give consent and permission for representatives from the T.E.A.M. Dad program to contact me to learn more about the program and determine eligibility. By consenting to be contacted (or consenting for my son if he is a minor) and submitting my information, it does not mean that I am automatically enrolled in the program, and I will still need to meet requirements to be accepted. I also understand that any information shared will be held confidentially and I can decline services at any time.

I have read this Consent before signing or verbally agreeing to be referred and fully understand the contents, meaning and impact. I understand that I am free to address any specific questions and have done so prior to signing this Consent.
Father's Name*

First NameLast Name
Father's Date Of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Mother's Name*

First NameLast Name
Mother's Date Of Birth*

MonthDayYear
Date
Child's Name (must be under 3 years old)

First NameLast Name
Child's Date Of Birth (or Pregnancy DUE DATE)*

MonthDayYear
Date
Languages spoken (Please select ALL that apply)*

EnglishCreoleSpanishOther
Email
example@example.com
Signature of Father*

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Today's Date*

MonthDayYear
Date
Section below is REQUIRED only if the father is under age 18
Name of Parent / Legal Custodian

First NameLast Name
Signature of Parent / Legal Custodian

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REQUIRED: Was verbal consent obtained? (Consent must come directly from Father)
If referred by CIR or Healthy Start, please provide WFS case ID#:
If consent was verbal, how was consent obtained? (REQUIRED)

Intake Coordinator spoke to the father by phone during telephonic CIR intakeIntake Coordinator spoke to the father by phone during the CIR intake at hospital bedside or during a clinic appointmentHS home visitor spoke to father by phone during a home visitHS home visitor spoke to father by phone during a clinic appointmentDuring a community event
Verbal Consent Obtained by?

First NameLast Name
Email address of referring CIR or Healthy Start worker:
Phone number of referring CIR or Healthy Start worker:
Should be Empty:

Authorization / Consent for Referral to Fatherhood Program

Please Read Paragraph below to Father when obtaining Verbal Consent

Section below is REQUIRED only if the father is under age 18