Consent to Participate in The Healing Tree SCD

Consent to Participate in The Healing Tree SCD
Patient Name*

First NameLast Name
Parent Name*

First NameLast Name
Name of Hospital Where You Receive Treatment*
Additional Patient(s) in your family
I First Name* Last Name* give my consent to participate in The Healing Tree SCD. (Self/Parent/Personal Representative)
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 insuranceTutoringThe Rooted in Resilience Mentor Learner Program
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. If my tutor, mentor or food coach identify specific needs such as obtaining information from my school, identifying therapuetic support, helping with financies or engaging a social worker, I give the Healing Tree SCD permission to contact the social worker at Nemours Children's Health on my behalf.
(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 SCD.
(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 of Person Giving Consent*

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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