OKC Empower Parent Family Registration and Policy Acknowledgements

Family Registration Form
Date*

MonthDayYear
Date
Parent 1 Name*

First nameLast name
Date of Birth*

MonthDayYear
Date
Preferred name if different
Relationship to Children*
Email*
example@example.com
Phone number*
Address*

Address

Street Address Line 2

CityState

Zip code
CLIENT CHARACTERISTICS Race- Select all that apply*

African American/BlackAmerican Indian or Alaskan NativeAsian or Pacific IslanferCaucasian/WhiteOther
Ethnicity*

Hispanic OriginNon Hispanic Origin
Gender*
Are you currently pregnant?*

YesNo
If yes what is your due date

MonthDayYear
Date
Language (Mark all that apply)*

EnglishSpanishOther
Marital Status*

SingleMarriedDivorcedWidowDomestic PartnershipOther
Employment Status*

Full TimePart TimeUnemployedUnderemployedSelf-employedOther
Employer name contact information*
Financial Assistance*

TANFSNAPMedicaid/Sooner CareDHS Child CareNoneOther
Religion*

Christian/ProtestantCatholicJewishOther
Parent 2 Name (if appicable)

First nameLast name
Date of Birth

MonthDayYear
Date
Preferred name if different
Relationship to Children
Email
example@example.com
Phone number
Address

Address if different

Street Address Line 2

CityState

Zip code
Client Characteristics (Mark all that apply)

African American/BlackAmerican Indian or Alaskan NativeAsian or Pacific IslanderCaucasian/WhiteOther
Ethnicity

Hispanic OriginNon Hispanic Origin
Gender
Are you currently pregnant?

YesNo
If yes when if your due date

MonthDayYear
Date
Language (Mark all that apply)

EnglishSpanishOther
Marital Status

SingleMarriedDivorcedWidowDomestic PartnershipOther
Employment Status

Full TimePart TimeUnemployedUnderemployedSelf-employedOther
Employer name contact information
Financial Assistance

TANFSNAPMedicaidDHS Child CareNoneOther
Religion

Christian/ProtestantCatholicJewishOther
1 Child Information (if applicable)
Name*

First nameLast name
School*
Grade*
Date of Birth*

MonthDayYear
Date
Gender*
Race (mark all that apply)*

African American/BlackAmerican Indian or Alaskan NativeAsian or Pacific IslanderCaucasian/WhiteOther
Ethnicity*

Hispanic OriginNon Hispanic origin
Financial Assitance*

TANFSNAPMedicaidDHS Child CareFree and Reduced LunchNoneOther
Religion*
Is this child involved in any activities? (If yes, select from below)*

YesNo
Activities your child participates in*

Lilyfield after-school programCornerstoneCheck and connect (Americorps)School-based after school programSportsOther
2. Child Information (if applicable)
Child Name

First nameLast name
School
Grade
Date of Birth

MonthDayYear
Date
Gender
Race (mark all that apply)

African American/ BlackAmerican Indian or Alaskan NativeAsian or Pacific IslanderCaucasian/ WhiteOther
Ethnicity

Hispanic OriginNon Hispanic Origin
Financial Assistance

TANFSNAPMedicaidDHS Child CareFree or Reduced LunchNoneOther
Religion
Is this child involved in any activities?

YesNo
Activities this child participates in

Lilyfield after-school ProgramCornerstoneCheck and Connect (Americorps)School-based After-school ProgramSportsOther
3. Child Information (if applicable)
Name

First nameLast name
School
Grade
Date of Birth

MonthDayYear
Date
Gender
Race (mark all that apply)

African American/ BlackAmerican Indian or Alaskan NativeAsian of Pacific IslanderCaucasian/ WhitOther
Ethnicity

Hispanic OriginNon Hispanic Origin
Financial Assistance

TANFSNAPMedicaidDHS Child CareFree or Reduced LunchNoneOther
Religion
*Is this child involved in any activities? (If yes, select from below)

YesNo
What activities does this child participate in?

Lilyfield After-school programCornerstoneCheck and Connect (AmeriCorps)School-based after-school programSportsOther
4. Child Information (if applicable)
Name

First nameLast name
School
Grade
Date of Birth

MonthDayYear
Date
Gender
Race (mark all that apply)

African American/BlackAmerican Indian or Alaskan NativeAsian or Pacific islanderCaucasian/ WhiteOther
Ethnicity

Hispanic OrigninNon Hispanic Origin
Financial Assistance

TANFSNAPMedicaidDHS Child CareFree or Reduced LunchesNoneOther
Religion
Is this child involved in any activities?

YesNo
If yes, What activities is the child invloved in?

Lilyfield after-school programCornerstoneCheck and Connect (AmeriCorps)School-based after-school ProgramSportsOther
Household Composition (mark all that apply)*

Single family householdLive with other familySingle parent homeLives with parent(s)/guardian(s)Lives with grandparentsLives with foster parent(s)Other
Household monthly income*

$0-$500$501-$1000$1001-$1500$1501-$2000$2001-$2500$2501+Prefer not to answer
Number of people in household*
Reason for seeking services*
Are there any barriers to accessing our services*
Emergency contact*
Relationship*
Phone number*
Second Emergency contact Name*
Relationship*
Phone number*
Client Signature*

Clear
Date*

MonthDayYear
Date
Staff Signature

Clear
Date

MonthDayYear
Date
Wenamegive Lilyfield permission to use photographs, quotes and We, information regarding our family for public relation publications. We understand this publication may be made available on the Lilyfield website, publications, Lilyfield events, and in other public venues.
We hereby waive the right to inspect or approve the images, quotes or the publication prior to any form of usage. We understand the images may be modified to be used as design elements.
By signing this agreement, we are releasing all rights to any images, quotes and the publication.
Indicate your selection below by circling the desired response:
You may use photos of our children
You may use our photos*

YesNo
You may use our quotes*

YesNo
You may use our first names*

YesNo
You may use our last names*

YesNo
You may use photos of our children*

YesNo
You may use our children's names*

YesNo
Names of children included in this release: *
Caregiver Signature*

Clear
Date*

MonthDayYear
Date
2nd Caregiver Signature

Clear
Date

MonthDayYear
Date
Adverse Childhood Experience (ACE) Questionnaire Finding your ACE Score

While you were growing up, during your first 18 years of life:
1. Did a parent or other adult in the household often …Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt?*

YesNo
If yes enter 1
2. Did a parent or other adult in the household often … Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured?*

YesNo
If yes enter 1
3. Did an adult or person at least 5 years older than you ever…Touch or fondle you or have you touch their body in a sexual way? or Try to or actually have oral, anal, or vaginal sex with you?*

YesNo
If yes enter 1
4. Did you often feel that … No one in your family loved you or thought you were important or special? or Your family didn’t look out for each other, feel close to each other, or support each other?*

YesNo
If yes enter 1
5. Did you often feel that … You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?*

YesNo
If yes enter 1
6.Were your parents ever separated or divorced?*

YesNo
If yes enter 1
7. Was your mother or stepmother: Often pushed, grabbed, slapped, or had something thrown at her? or Sometimes or often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?*

YesNo
If yes enter 1
8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?*

YesNo
If yes enter 1
9. Was a household member depressed or mentally ill or did a household member attempt suicide?*

YesNo
If yes enter 1
10. Did a household member go to prison?*

YesNo
If yes enter 1
Now add up your Yes answers*
Protective Factors and Hope Scale

Instructions: Please read each statement and select a number between 1 and 8 that best reflects your experience or perspective from the scale below:

1. Definitely False 2. Mostly False 3. Somewhat False 4. Slightly False 5.Slightly True 6. Somewhat True 7. Mostly True 8 . Definitely True
1. I am able to work through hardship stress and tragedies in my life*
2. I have family and/or friends in my life that I enjoy spending time with, and I spend time with them regularly.*
3. I am able to find resources for daily needs when necessary*
4. I have learned parenting skills and understand how my children learn and grow.*
5. My child is able to make friends and share their feelings with me. (If you have more than one child, please provide an average answer.)*
6. I can think of many ways to get out of a jam.*
7. I energetically pursue my goals.*
8. There are lots of ways around any problem.*
9. I can think of many ways to get the things in life that are most important to me.*
10. Even when others get discouraged, I know I can find a way to solve my problem.*
11. My past experiences have prepared me well for my future.*
12. I've been pretty successful in life.*
13. I meet the goals that I set for myself.*
Todays Date*

MonthDayYear
Date
Name*
Class or Group Attending*
Location*

OKC areaTulsa area
Informed Consent

Services Provided: Parents who participate in the program will have access to all levels of service through Empower Parents which include structured parent education groups, parent peer support groups, and individual peer mentoring. No service will be provided without parent/guardian consent. EmpowerOKC services are voluntary and there is no cost to you or your family. You are free to limit or end services at any time. Confidentiality: Lilyfield will keep the information you share confidential, unless we have written consent to disclose certain information. There are important exceptions to this rule. In some situations, we are required by law or by the guidelines of professional rules and regulations to disclose information whether or not we have your permission which are as follows:

You tell us that you plan to cause serious harm or death to yourself, and we believe you have the intent and ability to carry out this threat in the near future. You tell us that you plan to cause serious harm or death to someone else who can be identified, and we believe you have the intent and ability to carry out this threat in the very near future. You tell us that you are being physically, sexually or emotionally abused or we have a reasonable suspicion that a minor under the age of 18 is the victim of abuse or neglect. We are required by law to report the abuse to the Oklahoma Department of Human Services. Your information regarding counseling is subpoenaed by the court. We may be required to

disclose information to the court.

Crisis Response: Lilyfield Staff, AmeriCorps members, and volunteers are not mental health professionals and therefore not equipped to respond to mental health crises, including but not limited to suicidal thoughts or ideations. Clients served by Lilyfield who demonstrate symptoms of a mental health crises will be referred to appropriate mental health resources. If an individual is experiencing a mental health crises, the following resources may be accessed.

911 Emergency Oklahoma Department of Mental Health Crisis ReachOut Helpline 1-800-522-9054

Crisis Text Line Text HELLO to 741741

National Adolescent Suicide Helpline 1-800-621-4000
Notice of Grievance Right

Lilyfield's Empower Program wants to ensure that all clients are ensured fair consideration of complaints made by clients, including children, and guarantee a quick resolution to any complaint. You have a right to file a grievance, receive written response to your grievance and to appeal if you are not satisfied with the response you get. You have a right to report allegations of abuse, neglect, and mistreatment. If anyone attempts to deny you these rights or causes you problems in filing a grievance, contact your Grievance Coordinator immediately.

Who May File a Grievance: Any client receiving services through Lilyfield's Empower Program or any person interested in this client's welfare. (This could be your parent/guardian, foster parent, mentor, or attorney)

What Complaints Are Considered: The complaint may be about any policy, rule, decision, behavior, and action or condition made or permitted by Lilyfield employees.

How to File a Grievance: Write your complaint down and include how you wish to resolve this problem. If you are unable to write, then your worker will help you write out your complaint. You have 30 working days from the date of your complaint to file your grievance. If your complaint is against a Lilyfield employee, you may wish to contact the Empower Coordinator or Director of Lilyfield for help with the complaint.

What Happens Next: You will receive a written response within 10 working days after turning in your grievance. The Grievance Coordinator will meet with you to discuss the response to your grievance. If you are unhappy with their response, you may ask for a second level review of your complaint.

Should you wish more information about your right to file a grievance and the procedures involved, please contact Tiffany Hooper at the following telephone number: (405) 216-5240.
Lilyfield Client Rights

It is the policy of Lilyfield, Inc. to provide all clients with the following rights:

1.To access Lilyfield's services during our office hours of 8:30 a.m.-5 p.m. Monday-Friday. Evening appointments are available by appointment only.

2. To be treated with dignity and respect.

3. To receive services in a non-discriminatory manner.

4. To be free to express and practice spiritual and religious beliefs.

5. To be informed of Lilyfield's policies and procedures which relate to them and/or their child's care and any changes made to these policies and procedures.

6. To receive consistent enforcement of program rules and expectations.

7. To experience an environment free of neglect or abuse of any nature, including but not limited to sexual, physical, or verbal.

8.To receive services in a manner that is non-coercive and that protects the person's right to self- determination.

9. To have personal information protected from unauthorized disclosure without their written consent to release their information except as required by law to protect a child or someone else from physical danger, abuse or neglect, to respond to a legal subpoena, or to report evidence related to criminal behavior.

10. To expect phone calls and other correspondence, such as letters or e-mails, to be returned in a timely

11. To have access to appropriate support services for themselves and/or their child.

12. To have the correct contact information for the agency and the primary worker assigned to them.

13. To file a grievance and be informed of the process for filing a grievance.

14. To be provided with prompt, competent, and appropriate treatment and to allow other individuals of the client's choice to participate in the treatment.

15. To receive services that are respectful of, and responsive to, cultural and linguistic differences.

16. To receive accommodations, as appropriate, related to the visual, auditory, motor abilities, or written and oral communication needs of the client asnecessary.

17. To refuse any service, treatment, or medication unless mandated by law or court order; and

18. To be informed of the consequences of such refusal, which can include discharge
Technology Based Service Disclosure

When and How They Are Offered: In the event of inclement weather, illness or sickness, lack of transportation, site closure or additional unforeseen barriers, Lilyfield may offer technology-based services. Lilyfield's services are intended to be received in person. An attempt to reschedule in-person services will be made first. Personnel and staff will communicate on an ongoing basis to assess the need for technology-based services. The client is responsible for communicating any change in barriers or challenges preventing access to technology-based services. Personnel will explain the program before the services begin. Client participation in this is totally voluntary and may decide to stop services at any time.

Digital Confidentiality: The safety of our clients and their families is a top priority at Lilyfield. Please keep in mind that technology-based services are not guaranteed to be secure. Virtual services will be provided in confidential locations, using Microsoft Teams. The client understands that, while secure and compliant platforms are used, there may be an increased security risk associated with internet usage. It is understood that clients should use a secured internet connection and use the program in a private place where others cannot overhear confidential information. The standards for group confidentiality during in- person services are also expected to be upheld during virtual sessions. Lilyfield prohibits taking photographs, video recordings, screenshots, and sharing any personal information of other participants. Lilyfield will make every attempt to ensure client privacy and confidentiality are protected but acknowledges that other parties may not adhere to the same standard. When receiving services over video, anyone can see who is in the room at the other site.

Crisis Response: Lilyfield staff should ascertain the client's location at the beginning of each session, if possible, to best respond in a crisis. If a client experiences a crisis while teleservices are being used: a. Find out the location of the client if not already known. b. Call 911 if the client presents an imminent danger to self or others C. Call client's parent/guardian if client is a minor d. Provide appropriate referrals for the caregiver to ensure safety. Referral services may include referrals to the Emergency Room, the Oklahoma County Children's Mobile Response Unit, and coordination with local law enforcement.
Acknowledgment of Lilyfield Policies and Procedures
Client Name print*
Date of Birth*

MonthDayYear
Date
I. I have read and understand the Lilyfield Informed Consent. I consent to receive services.*
II.I have received, read and understand the Lilyfield Notice of Grievance Rights. I have received a copy of this document.*
III. I have received, read and understand the Lilyfield Clients Rights. I have received a copy of this document. *
IV. I have received, read and understand the Technology Based Service Disclosure I have received a copy of this document.*
Client Signature*

Clear
Date*

MonthDayYear
Date
Authorized Signature if minor

Clear
Date

MonthDayYear
Date
Printed name of authorized person
Relationship to Minor
OKDHS Signature if applicable

Clear
Date

MonthDayYear
Date
FOR OFFICE USE ONLY - AGENCY REPRESENTATIVE
Each of the documents listed above were explained by name and title
A copy of each was provided to the client and authorized parent guardian if minor
Consents signatures were obtained by the client and authorized parent guardian if minor on
Agency Representative Signature

Clear

Flourishing Measure

Please respond to the following questions on a scale from 0 to 10:
1. Overall, how satisfied are you with life as a whole these days? 0 = Not Satisfied at All, 10 = Completely Satisfied*
2. In general, how happy or unhappy do you usually feel? 0 = Extremely Unhappy, 10 = Extremely Happy*
3. In general, how would you rate your physical health? 0= Poor, 10 = Excellent*
4. How would you rate your overall mental health? 0 = Poor, 10 = Excellent*
5. Overall, to what extent do you feel the things you do in your life are worthwhile? 0 = Not at All Worthwhile, 10 = Completely Worthwhile*
6. I understand my purpose in life. 0 = Strongly Disagree, 10 = Strongly Agree*
7. I always act to promote good in all circumstances, even in difficult and challenging situations. 0 = Not True of Me, 10 = Completely True of Me*

8. I am always able to give up some happiness now for greater happiness later. 0 = Not True of Me, 10 = Completely True of Me*
9. I am content with my friendships and relationships. 0 = Strongly Disagree, 10 = Strongly Agree*
10. My relationships are as satisfying as I would want them to be. 0 = Strongly Disagree, 10 = Strongly Agree*
11. How often do you worry about being able to meet normal monthly living expenses? 0 = Worry All of the Time, 10 = Do Not Ever Worry*
12. How often do you worry about safety, food, or housing? 0 = Worry All of the Time, 10 = Do Not Ever Worry*
These 12 items have been used around the world toassess various domains of flourishing, or human well-being: Happiness and LifeSatisfaction (Items 1-2), Mental and Physical Health (3-4), Meaning and Purpose(5-6), Character and Virtue (7-8), and Close Social Relationships (9-10). Asixth domain, Financial and Material Stability (11-12) may be necessary tosustain the other domains over time. The background and motivation for theseitems and the flourishing domains can be found in:VanderWeele,T.J. (2017). Onthe promotion of human flourishing. Proceedings of the NationalAcademy of Sciences, U.S.A., 31:8148-8156. HumanFlourishing Program, at Harvard University Program Website: https://hfh.fas.harvard.edu/
Should be Empty:

Family Registration Form

1 Child Information (if applicable)

2. Child Information (if applicable)

3. Child Information (if applicable)

4. Child Information (if applicable)

Acknowledgment of Lilyfield Policies and Procedures

Flourishing Measure