Youth Diversion Programming

Program Participation Agreement & Consent for Services

Welcome to Youth Diversion programming offered through Family Service Agency's Youth Programming department. We aim to provide supportive programs and services to our clients based on the individual needs identified during the intake assessment. All programs strive to promote positive growth, prevent further justice involvement, and support both youth and families. Please review the general programming information outlined below:

• There is no cost to enroll in Youth Diversion programming
• An ID for the parent/guardian is required to register for the program
• An ID for the child/participant is requested but not required to enroll in the program (the child/participant's ID may be state issued or school issued)
• If a client is unable to attend a scheduled group session, they must attend a make up session the following week in order to receive credit for the lesson
• Clients may be removed from the program if more than 2 group sessions are missed

Expectations for Youth Diversion Programming:

• Participation in assigned programs is mandatory unless agreed otherwise with FSA and JCS
• Regular attendance and active engagement are expected
• Open communication with facilitators is essential for success
• All participants must commit to respectful, confidential, and safe conduct

Youth Diversion Programming Infractions:

• Refusal to adhere to the cell phone policy
• Use of drugs, alcohol, or vapes
• Failure to meet participation expectations
• Violation of treatment rules, including verbal threats, acts of violence, or disrespect toward any Family Service Agency staff member

Certificate of Completion:

In order to receive a certificate of completion, a client must meet the following criteria:

• Attend all assigned sessions
• Attend the initial individual assessment session
• Abide by all outlined rules and regulations of the program

1. I seek and consent to participate in services at Family Service Agency's programs.

2. I understand that developing a treatment plan with my counselor and regulary reviewing progress towards my treatment goals is in my best interest.

3. I understand that I may stop program services at any time and that I am responsible for any consequences of terminating counseling.

4. I understand and have discussed with my counselor: a.) my condition, problem and/or diagnosis, b.) the planned course of treatment, c.) alternatives to treatment, including no treatment and d.) confidentiality and the limits or exceptions of confidentiality.

5. I understand as the parent or guardian of a recipient of services who is at least 12 but under 18 years of age that my child has rights to confidentiality that are different than for a child under 12 years of age. I understand the following provisions: a.) Any minor 12 years of age or older may request counseling services without the consent of the parent or guardian. b.) Sessions provided to a minor age 12-17 without parent or guardian consent shall be limited to not more than 7 sessions, lasting no more than 45 minutes each. c.) If a minor child age 12-17 chooses to consent to counseling without parent or guardian consent, then the parents will not be informed unless required by law. d.) If a minor child age 12-17 chooses to consent to counseling withouth parent or guardian consent then the parents are not financially responsible for those sessions. e.) Parent or guardian is not entitled access to protected health information of a child age 12-17 without the child's consent, unless required by law.

6. If the person to receive services is a minor (under the age of 18 years of age), I give permission to the program services to provide services to him or her.

7. I understand that a child age 17 or under who has been a victim of criminal sexual assault or abuse may consent to program services without parent or guardian consent.

8. I give consent for Family Service Agency to contact me for evaluative purposes.

I hereby give consent to Family Service Agency of DeKalb County [1325 Sycamore Rd., DeKalb, IL., 60115  (815) 758-8616] to realease and/or exchange protected mental health information and/or program information concerning the above-named client in written, oral, or electronically to the following person or entity:

I understand that:

• I have the right to obtain a copy of my own protected health information.
• I have the right to revoke this authorization at any time, I must do so in writing to the medical records department, I may not revoke for information that has already been authorized and disclosed.
• Re-disclosure of information is prohibited without written consent, that being stated, Family Service Agency cannot prevent an entity to which it is disclosing to from re-disclosing the information on their own accord.
• Authorizing to disclose protected health information is voluntary and not required for treatment, payment, or benefits.
• Form must be filled out in its entirety for request to be honored.
• Fees may be charged for records per all laws applicable to release of protected health information.
• My record may contain information pertaining to Sexually Transmitted Disease (STD), Acquired Immunodeficiency Syndrome (AIDS), or Human Immunodeficiency Virus (HIV).