Consent to Participate in The Healing Tree SCD

Consent to Participate in The Healing Tree SCD
I First Name* Last Name* give my consent to participate in The Healing Tree SCD. (Self/Parent/Personal Representative)
I receive healthcare at _________ Nemours Children's Health in Wilmington DE or
_________ Christiana Hospital, Wilmington DE. Please check one.
I am interested in learning more about the following offerings:*

The NOURISH ProgramThe Sunny Day FridgeSCD Family Fellowship Support GroupTransportation to and from clinic appointmentsVitamins not covered by insuranceVocational or educational assistance.
In consent to participate in the Healing Tree I acknowledge and agree to the following:
(1) My medical treatment is not conditional in any way on participating in this program.
(2) If I do not sign this form my healthcare and the payment for my healthcare will not be affected.
(3) I understand that the contact information I provide may be shared with a volunteer who will provide some of the services listed above. I further understand that the Healing Tree will share with the volunteer only the minimum amount of information necessary to provide services to me and my family.
(4) I authorize The Healing Tree to inform my provider that I am using one or more services.
(5) I may revoke this consent at any time.
(6) I understand there may be a separate intake form for some of the services and my participation in surveys concerning the quality and impact of services may be requested.
(7) If I have questions about this consent or any of the program services, I can discuss them with my/my child’s care team and/or the Director or Navigator of the Healing Tree.
(8) I can request a copy of this consent after I have signed it.
Healing Tree Participant Information Form
(9) I understand and give permission to the hospital to coordinate transportation services on my behalf with GoGo Transport, paid for by The Healing Tree SCD.
Name*

First NameLast Name
Date*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Best method of contact*

PhoneEmail
Signature of Patient, Parent or Representative *

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