FAMILY SERVICE GUIDELINES

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Client Name

FAMILY SERVICE GUIDELINES

The sessions will be coordinated between the family and the service provider. In order to render services, the youth must be present.

In each meeting the family will sign documentation that will confirm that the services were provided as follow: A completed Encounter form will be provided at the end of each session by the provider. Such a form should include the date, time and length of each visit, and should be completed at the end of the session, prior to asking family for signature.

Family advised not to sign any pre-date or blank encounter forms. If this were to occur, please contact Working Towards a brighter future (WTBF) Director Immediately at 347-972-5221.

The provider will not collect money from the families directly. Please inform the agency if the provider cancels more than one appointment in a row or does not show up to scheduled visits.

You will receive regular telephone calls from WTBF to ensure your on-going satisfaction with services. Upon Completion of services, you will receive a final telephone call (or letter) from WTBF to complete a satisfaction survey. Your opinions of our service are very important to us.

Please be advised that all the information provided is confidential and will not be disclosed to third parties without the guardian or the youth (if older than 14) signing a release of information.

Confidentiality may be waived if the minor reports sexual, physical or any other type of abuse. The provider may disclose this information, without consent, to the Division of Child Protection and Permanency (formerly known as Division of Youth and Family Services), as required by law. If the youth reports suicidal ideation or plans the provider has the responsibility to assess risk and take the necessary steps to guarantee the wellbeing of the child.

“We thank you for allowing us to come into your home. We will strive to make this experience as positive one and help your family achieve your goals”.

I have received and read the terms and conditions of this document; I am also aware of the limits of engagements by my mental health care provider(s). I (Guardian’s name) agree for (Youth’s name) to receive services from the providers of WTBF. I certify that I understand the terms of this agreement.
Guardian
Date
Youth (14+)
Date
Provider
Date