Healthy Relationships

Healthy Relationships

Consent for Participation
Participant's Name*

First NameMiddle InitialLast Name
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If the person participating in the WEAVE Healthy Relationships group services has a legal guardian responsible for consenting to their participation in services, please complete the following information:
Legal Guardian's Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Is the service participant connected with an outside agency (i.e., Adult Foster Care Home, Disability Service Provider, Community Agency, etc.) who WEAVE will be working with in providing services?*

YESNO
If you answered yes, please identify the agency in which the services participant is affiliated with:

Spectrum Community ServicesThresholdsMOKAHope NetworkOther
In order to provide comprehensive service, it is often helpful for Healthy Relationship group facilitators to coordinate services with the Adult Foster Care Home and/or Disability Service Provider. Do we have your permission to contact the agency identified above?*

YES (a full release of information will be completed)NO you may not
I understand that participation in the WEAVE Healthy Relationships group is voluntary and the individual directly participating may withdraw from services at any time. I also understand that the person participating in the WEAVE Healthy Relationships group and/or the individual legally responsible for consenting to their participation in services (i.e. parent and/or legal guardian), has the right to refuse any service, treatment, or intervention at any time.

I have received the Welcome Letter and Privacy Statement, which describes service participant’s rights to confidentiality, program expectations, and the grievance/appeal process if there are concerns about services. I agree with the conditions outlined in these documents.

I understand that in order to facilitate ongoing funding for services, demographic and satisfaction data is collected and submitted to the Michigan Department of Community Health on a quarterly basis. The service recipient’s information is combined with all other program participants to form a picture of how the services of the program are impacting the community. No identifying information is ever released.

I understand that during assessment and/or services that the receipt receives, any information shared is confidential except for circumstances involving abuse or neglect of children or vulnerable adults, or the threat of suicide or homicide. The law requires that concerns regarding the types of abuse and neglect listed above, be shared with officials for further investigation. I understand that if the person receiving services tells a treatment provider that they intend to harm another individual or himself/herself, the treatment provider may have to notify the person under potential harm or appropriate authorities or family members to ensure safety.

In signing this form, I certify that I have read and understand the information outlined above. I hereby authorize the YWCA West Central Michigan, through it’s staff and/or contract agents, to provide GROUP EDUCATION, SUPPORT, and THERAPY services to the service participant identified above.
Participant's Signature*

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Date*

MonthDayYear
Date signed by participant
Parent and/or Legal Guardian's Signature (if applicable)

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Date

MonthDayYear
Date signed by parent and/or legal guardian
Witness Signature ____________________________________________

Date signed by witness __/__/____
Should be Empty: