Case Conference Parent/Guardian Consent Form

Case Conference Parent/Guardian Consent Form

The Fulton County KIDS Project (1994a) in Hickman, Kentucky, developed the following form to show parent/guardian consent for sharing information:

"Case Conference Parent/Guardian Consent

Child/Youth Identification:

Name________________________________ Date of Birth_________________

Address______________________________ S.S.#________________________

Parent/Guardian________________________ Phone______________________

Address (if different from child/youth)____________________________________

Permission for Service:

Permission is hereby given to the staff of the agencies participating on the Fulton County KIDS Project case conference team, as listed below, to render services to _______________________, whose relationship to me is____________________.

Release of Information:

I, as parent/guardian of the above-named child/youth, hereby consent to the release of information by the participating agencies within the Fulton County KIDS Project for oral presentation only at a case conference meeting to be held on _____________________. This information will not be released to other nonparticipating agencies/persons without my express written consent. I understand and have had explained to me that this sharing of information will enable the participating agencies to provide my child/family with the most efficient and effective services. This release consent shall remain in effect for a period of time beginning __________________ and ending __________________ but may be withdrawn at any time upon my written request to any participating agency.

Signatures:

Parent/Guardian ________________________ Date________________

Agency Staff___________________________ Agency______________

I understand that the following agencies will be participating as needed in this case conference and will be exchanging oral information concerning my child/youth and family.

Department of Vocational Rehabilitation
Department for Social Services
Department for Social Insurance
Purchase District Health Department
Department for Employment Services
Murray Head Start
Fulton County School District
Fulton Independent School District
Western Kentucky Regional MH-MR Board, Inc.
Administrative Office of the Courts - Juvenile Services
Kentucky Commission for Children with Special Health Needs"

References