Client Services Consent Form

Nature of Service

I understand that I am seeking services from SARC, a nonprofit organization providing support for those affected by domestic and sexual violence. Services may include non-legal services such as crisis intervention, counseling, advocacy, safety planning, referrals, psychoeducation, and other supportive services as determined by my needs. I understand there are multiple programs within SARC and I may be asked to sign consent forms if I chose to engage with a specific program. SARC strives to meet the needs of every client however there may be times when our services are not the best fit for an individual’s specific needs. During the assessment process, the client and advocate will work together to review available options and determine the most appropriate course of action, which may include referrals to other resources for additional support.

Understanding of Services

I acknowledge that at this time, I may not yet know which services I need. By signing this form, I am giving initial consent to engage with a SARC staff member to explore my options and determine what support might be most helpful. As part of this process, I understand that I may be contacted by phone or video to complete an initial meeting, screening, or case assessment. These conversations are not clinical counseling sessions, but they are designed to assess my needs and connect me with appropriate services or referrals. Due to the sensitive nature of the topics discussed, I understand that it is important to be in a private, confidential location when speaking with a SARC staff member by phone or video. If I am not in a private setting or if there are safety concerns—such as the presence of an abusive partner or anyone who may compromise my safety or privacy, the meeting may be rescheduled or paused until a safe location can be confirmed. SARC takes steps to protect my privacy during virtual communication; however, I understand that phone or video calls may still involve some confidentiality risks, such as technical interruptions or someone overhearing on my end. I am encouraged to communicate openly with SARC staff if I have concerns about safety or privacy during our interactions. If I choose to engage in specific services beyond this initial meeting, I understand that I may be asked to provide additional consent.

Risks and Benefits

I understand that discussing my experiences may be difficult and bring up distressing emotions. However, these services are designed to support my safety, healing, and empowerment. Progress depends on various factors, including my level of participation and engagement with services.

Voluntary Participation

I understand that participation in services is voluntary, and I may withdraw consent at any time. If I choose to discontinue services, I am encouraged to discuss termination with SARC to ensure a proper transition.

Confidentiality and Limits

At SARC, we are committed to providing a safe, confidential space for all individuals seeking support. SARC Advocates are mandated reporters. Meaning we are required to report certain situations to ensure the safety and well-being of individuals. While your confidentiality is important, there are circumstances where we must break confidentiality in order to protect you or others. This includes situations where there is a risk of harm to yourself or others, or if there is suspected abuse or neglect involving a child, elderly person, or vulnerable adult. These reports are typically made to Child Protective Services or Adult Protective Services. In rare cases, if immediate danger is present, emergency services may be contacted. Staff will make sure to explain these situations to you and will only share the necessary information to ensure safety. If you have any questions or concerns about mandated reporting, please feel free to ask—we are here to support you through this process.

I understand I may not discuss or disclose another client’s information or publicly acknowledge another client’s involvement in SARC services without that person’s express permission. No identifying information will be released without my written consent. If I choose to share my information with another individual or service provider, I must complete a Release of Information form. This release can be revoked by me at any time. I understand a violation of this confidentiality policy may result in a review of services and could lead to suspension or termination of program participation.

I understand that my information will be kept confidential to the extent allowed by law. If I have any questions regarding confidentiality and mandating reporting I can ask a staff member for more information.

I understand domestic violence is a potentially lethal situation and in the event of my death, as a result of domestic homicide or suicide, I hereby waive my right to confidentiality. I understand information about my interactions with SARC may be discussed with other agencies as part of a learning process.

I wish to be contacted in the following manner (please check all that apply):

Emergency Situations

I understand that the Client Services phone number is not intended to serve as a crisis line. Any calls or messages received outside of agency operating hours will be addressed the following business day. If I need immediate support I will contact the SARC 24 hr. Helpline at 410-836-8430. My other options include the Mobile Crisis Team at 1-800-639-8783 or the National Suicide Prevention Lifeline at 988. In the event of an emergency I will call 911 or visit the nearest emergency room.

Acknowledgment and Consent

I have read, understood, and agree to the terms outlined in this document. I understand if have any questions related to this document I can ask the SARC Advocate I am working with for more information. This form will be valid for the duration of my participation in the Client Services Program at SARC but I can amend it at any time.