FAMILY RESPONSIBILITIES AND CONFIDENTIALITY POLICY

Program Description:

Our program supports the healthy development of high school youth by offering educational workshops in schools and community settings. We empower young people with the knowledge and skills to make informed decisions, set goals, and build a foundation for a successful future. Through interactive learning, we promote personal responsibility, healthy relationships, and positive decision-making to help youth navigate adolescence with confidence.

By signing this paperwork, you are agreeing for your child/ward to take part in this program, which includes:

Participation in after-school or during-school programming designed for high school youth.

The programming covers topics such as decision-making and planning, developing healthy relationships, addressing cyberbullying, understanding the impact of drugs and alcohol on relationships, healthy communication skills, self-awareness, problem-solving, dating violence prevention, and STI/HIV and pregnancy prevention education. Completion of anonymous questionnaires at two points 

• At the start of the program.
• At the end of the program.

Family Rights and Responsibilities:

Child & Family Resources, Inc. staff recognizes that families are crucial in the lives of our youth. Staff expects that families will participate in appropriate homework assignments and discussions, as outlined in written materials or requested by the group Facilitator Child & Family Resources, Inc. has established the following policies and procedures SO that the family's rights are protected. All families participating in the program have the following rights:

• The right to have your child/ward participate in the workshop and to provide feedback to staff and administration as needed;
• The right to refuse participation in evaluation tools and to terminate service at any time;
• The right to confidentiality of records and the right to access, upon request, one's own records.

This program is voluntary, and all staff are mandated reporters (ARS-13-3620 Your child/ward has a right to privacy, and any information obtained during the program that can be identified with your child's/ward's name will remain confidential as far as possible within state and federal law. If staff believes that your child/ward is in danger, you will be involved whenever it is reasonable to do SO. Child & Family Resources, Inc. believes that in many situations you can best help your child and ensure their safety. If there's a reasonable belief that your child is a victim of child abuse, physical injury, a reportable offense or neglect, or staff suspects a danger of harm to your child or to someone else, a report may be made to a law enforcement or/and Department of Child Safety (DES) 

Please fill out the information below highlighted in yellow to the best of your ability.

Additional Contact information for you child/ward:

CLIENT RIGHTS

All Clients have the following rights:

• To be treated with dignity, respect and consideration.
• Not to be discriminated against based on race, national origin, religion, gender, sexual orientation, age, disability, marital status, diagnosis or source of payment.
• To receive service that:
  • Supports and respects your individuality, choices, strengths and abilities;
  • Supports your personal liberty and only restricts your personal liberty according to a court order, by your consent, or as otherwise permitted by regulation; and
  • Is provided in the least restrictive environment that meets the Client’s treatment needs. 
• Not to be prevented or impeded from exercising your civil rights unless you have been adjudicated incompetent or a court of competent jurisdiction has found that you are unable to exercise a specific right or category of rights.
• To submit grievances to agency staff members and complaints to outside entities and other individuals without constraints or retaliation.
• To have grievances addressed in a fair, timely and impartial manner.
• To seek, speak to, and be assisted by legal counsel of your choice, at your expense.
• To receive assistance from a family member, designated representative or other individual in understanding, protecting or exercising these rights.
• If enrolled by the Department of Health Services or a Regional Behavioral Health Authority as an individual who is seriously mentally ill, to receive assistance from human rights advocates provided by the Department or the Department’s designee in understanding, protecting or exercising these rights.
• To have your information and records kept confidential and released only as permitted under R9-20- 211(A)(3) and (B);
• To privacy in treatment, including the right not to be fingerprinted, photographed or recorded without consent, except:
  • For photographing for identification and administrative purposes, as provided by A.R.S. §36-507(2);
  • For Clients receiving treatment according to A.R.S. Title 36, Chapter 37; or
  • For video recordings used for security purposes that are maintained only on a temporary basis according to R9-20-602(A)(5).
• To review or obtain a copy, upon written request, of your service record during the agency’s hours of operation.
• To review the following at the agency or at the Department of Health Services:
  • A.A.C. Title 9, Chapter 20;
  • The report of the most recent inspection of CFR conducted by the Department;
  • A plan of correction in effect as required by the Department;
  • The most recent report of inspection conducted by the Council on Accreditation for Children and Family Services (COA), a nationally recognized accreditation agency; and
  • Any plan of correction in effect as required by COA.
• To be informed of all fees, if applicable, that you are required to pay and of the agency’s refund policies and procedures before receiving a service, except for a service provided to a Client experiencing a crisis situation.
• To consent to treatment, unless treatment is ordered by a court of competent jurisdiction, after receiving a verbal explanation of the Client’s condition and the proposed treatment, including the intended outcome, the nature of the proposed treatment, and procedures involved in the proposed treatment, any risks or side effects from the proposed treatment and any altematives to the proposed treatment.
• To be offered or referred for the treatment specified in the treatment plan.
• To receive a referral to another agency if the agency is unable to provide a service that is requested or that is indicated in the treatment plan.
• To refuse treatment or withdraw consent to treatment unless such treatment is ordered by a court or is necessary to save the client’s life or physical health.
• To be free from:
  • Abuse;
  • Neglect;
  • Exploitation;
  • Coercion;
  • Manipulation;
  • Retaliation for submitting a complaint to the Department or another entity;
  • Discharge or transfer, or threat of discharge or transfer, for reasons unrelated to the Client’s treatment needs, except as established in a fee agreement signed by the Client or the Client’s parent, guardian, custodian or agent;
  • Treatment that involves the denial of:
    • Food;
    • The opportunity to sleep; or
    • The opportunity to use the toilet; and
    • Restraint or seclusion, of any form, used as a means of coercion, discipline, convenience or retaliation.
• To participate or, if applicable, to have the Client’s parent, guardian, custodian or agent participate in treatment decisions and in the development and periodic review and revision of the Client’s written treatment plan.
• To consent in writing, refuse to consent or withdraw written consent to participate in research or treatment that is not a professionally recognized treatment.
• To refuse to acknowledge gratitude to the agency through written statements, other media or speaking engagements at public gatherings.
• To receive services in a smoke-free facility, although smoking may be permitted outside the facility

CLIENT RESPONSIBILITIES

 As a Client of CFR, we ask you to understand that along with your rights, you have certain responsibilities as well. These include:

• Keeping your appointments. Please give ample notice (at least 24 hours) when you must cancel an appointment. You may be charged for broken appointments or late cancellations that occur within less than 24 hours of the appointment. This is important because we will be able to offer your time to someone else in need.
• Cooperating in the design and process of your service plan. Service may be terminated if you do not follow through on your fee agreement or service plan.
• Participating as appropriate and necessary in services for your children or children you have guardianship of.
• Paying your fees, if applicable, as agreed.
• Giving the information necessary to complete and process your application for service or program eligibility.
• Reporting any changes which may affect your fee or Client status.
• Being responsible for any children you bring to CFR. No children can be left unattended in the waiting area.
• Giving your consent for treatment of yourself and/or minor children at CFR.

CLIENT GRIEVANCE PROCEDURE
 

Most concerns are resolved by speaking directly to the staff member responsible for your care/services. Should you encounter a problem or conflict with a program staff member that has not been resolved to your satisfaction, please ask to speak with the program staff member’s supervisor. If still not resolved, you, as a client of Child & Family Resources, Inc., have the right to file a formal grievance regarding your care/services. Reasons for filing a grievance may include, but are not limited to, ineligibility determinations, service reductions, suspensions, termination, discrimination or quality of services.

 If you wish to file a grievance, please follow the instructions outlined below. If you need assistance in doing so, please contact the Program Director at your service site.

1.  Submit in writing within 90 days of the incident to the Program Director (or to the Service Line Vice- President, if the Program Director is involved in your grievance) of Child & Family Resources, Inc. a specific description of the problem or incident. Please include the following information:
   1. Your name, address, and telephone number.
   2. The program and location where you are receiving services.
   3. Date or dates on which the problem or incident occurred.
   4. Specific information regarding the problem or incident, including:
      • the problem;
      • staff members involved;
      • Other persons present or involved, etc.
   5. The action or actions you took or have taken to resolve or report the problem (as appropriate).
   6. The action you would like to be taken by Child & Family Resources, Inc. regarding the problem or incident.
2. The Program Director (or Service Line Vice-President, if the Program Director is referenced in the complaint) will review the grievance and submit a written response to you within ten (10) working days of receipt of the grievance. The Program Director or Service Line Vice-President may consult with the President/CEO, in formulating a response.
3. You have ten (10) working days in which to file a written appeal to the President/CEO of Child & Family Resources, Inc., if you are not satisfied with the written response.
4. The President/CEO has thirty (30) working days to review and provide to you a written response regarding your appeal.
5. If you are not satisfied with the response from the President/CEO, or at any time throughout the grievance process, you may appeal to the program funding source and utilize their grievance process. If there is no further process available, the decision of the President/CEO is considered final.

 

PARENT CONSENT FORM

Child & Family Resources, Inc.

Your child is being asked to take part in a voluntary program offered by Child & Family Resources, Inc., a local nonprofit organization, for you to decide whether or not to allow your child to be in this program, you should understand the procedures, risks, and benefits so that you can make an informed decision. The information in this form will help you learn about the program.

 

What is the Purpose of this Program?

The primary purpose of this research, funded by the U.S. Department of Health and Human Services Family and Youth Services Bureau, Administration for Children and Families, is to look at the effects of Sexual Risk Avoidance Education Programs on healthy development and decision-making skills, particularly in relation to sexual behavior and reducing teen pregnancy.

 What will participation in this Program involve?

If you agree to allow your child to participate in the program, your child will participate in a sexual risk avoidance education program that uses an evidence-based curriculum. The program addresses several issues important to youth, including relationships, responsible decision-making and planning for the future, positive gender roles, body image, self-acceptance, sexuality, and sexually transmitted infections/HIV education.

 All classes are offered to high school youth, and each class will have no more than 30 students. Your child will give you an outline of the topics of the class sessions after the first session. Your child will be asked to complete a survey (either online, or on paper) at the beginning and end of the program.

 

Who will be asked to be in the Program?

This program is only available to youth enrolled in high school grade levels who live in Apache, Pima, Maricopa, Gila, Pinal, Santa Cruz, Yuma, Yavapai, and Cochise Counties, Arizona who agree to be in the program and whose parent/legal guardian consents to their participating.

 

Are there any risks to being in the Program?

The program should be of minimal risk to your child. Some of the materials and questions might be of a sensitive nature. Your child does not have to answer any questions that make them feel uncomfortable. A highly trained group facilitator will be available to help your child with any concerns. During the program, if you have any questions or concerns related to this program, please reach out to the Program Director of Child & Family Resources, Inc. immediately.

 

Are there any benefits to being in the Program?

There are benefits to participating in the group.  These include learning decision-making, communication, coping skills, and social benefits from being part of the group. The evidence-based curriculum may include benefits related to teen pregnancy prevention and healthy decision-making around sexual health. This program will provide the U.S. Department of Health and Human Services Family and Youth Services Bureau, Administration for Children and Families with important information about how to improve programs for youth ages 14-17, including programs to help youth make healthy decisions and programs to prevent teen pregnancy.

Will there be any costs for being in the Program?

The only cost to your child being in this program is time.

Will there be payment for being a part of this Program?

Your child will receive incentives in the form of gift cards and/or small gift items in varying dollar amounts at various time points in the program. Gift cards will amount to $40 in total for completion of the following: a.) participation in the program, b.) Pre-test survey ($20), c.) Post-test survey ($20)

Will the information that is obtained be kept confidential?

Your child has a right to privacy, and any information obtained in this program that can be identified with your child’s name will remain confidential as far as possible within state and federal law. If we believe that your child is in danger, we want to involve you whenever it is reasonable to do so. We believe that in many situations you, as your child’s parent or guardian and primary caregiver, can best help your child and ensure their safety. If there’s a reasonable belief that your child is a victim of child abuse, physical injury, a reportable offense or neglect, or we suspect a danger of harm to your child or someone else, a report must be made to law enforcement or/and Child Protective Services.

Whom can you contact for more information?

If you have any questions about the information being collected or would like to look over materials related to the program the Program Director, Child and Family Resources, Inc. If you have any questions about your rights as a research subject, you may call the ARGUS Independent Review Board Chairman at (520) 298- 7494.  ARGUS IRB is an ethics committee established to help protect the rights and welfare of program participants.

Can I change my mind about my child being in the Program?

Your decision on whether or not to allow your child to be in this program is voluntary. Choosing to not have your child be in the program will not affect you, your child, or any of the services in which you or they participate in now or in the future. You or your child may decide to stop participation at any time. If you decide that you do not want your child to complete questionnaires, they can continue to attend the program classes if you choose.

 

AUTHORIZATION:

1. By signing this form, I agree with the statements below under authorization and chosen yes or no to the publicity release statement.
   1. I state that I have read and understood the information provided to me. I have been given the opportunity to discuss this information with staff and have my questions answered, and that I agree to have my child take part in this program. I do not give up any of my legal rights by signing this form. I understand that I will be given a copy of this consent form after signing it. I understand that my child taking part in this program is voluntary and that I may remove them from the program at any time after signing this form without penalty
   2. I/We have read or have had read to me/us Child & Family Resources, Inc.'s statement of policy describing my/our rights and responsibilities as a Client of the agency. I/We understand my/our rights and agree to carry out my/our responsibilities. I/We have received a copy of the Client Rights and Responsibilities statement, as well as a copy of the Child & Family Resources, Inc. Client Grievance Procedure 
   3. I/we give consent to Child & Family Resources, Inc. to provide services for my child.

PUBLICITY RELEASE:

D. Child & Family Resources, Inc. and members of the medial occasionally create slides, photographs and/or video tapes of the different programs CFR offers to children, parents, families and/or childcare providers in the community. These materials are used to inform others about the services that Child & Family Resources, Inc. provides as well as to inform potential funding groups. These materials may also be included in any/all of Child & Family Resources publications and in the local media. Your or your child's likeness, voice or artwork will only be used with your informed consent.