General Consent Form Este campo está oculto cuando se visualiza el formularioGUIDEste campo está oculto cuando se visualiza el formularioreqCodeEste campo está oculto cuando se visualiza el formulariouserEmail Este campo está oculto cuando se visualiza el formularioGUTYPEEste campo está oculto cuando se visualiza el formularioSubmission Date (Admin Only) DD barra MM barra AAAA I hereby consent to the program administrators releasing and/or disclosing personal information related to myself to participating service providers and partners, as outlined below. PARTICIPATING PARTNERS Participating partners may include, but are not limited to, education providers, health services, justice and legal services, municipal services, housing and income support programs, child and family services, community-based organizations, and other relevant public or non-profit service providers involved in collaborative support planning. I am consenting to the disclosure of this information to participating partners to allow for collaborative planning and coordinated support for the purposes of: Early identification of risk factors and/or barriers to safety, stability, and success Coordination of multi-partner case planning for individuals, children, youth, and families Mobilization of public and/or private, community, and family supports Navigational and referral support Proactive planning to reduce crisis situations and provide crisis intervention and support I am also agreeing to the following: To participate in the program with the intention of working toward safety, stability, and success To communicate respectfully with program staff if I am unable to keep appointments or if barriers arise that affect my ability to follow agreed-upon plans I understand the following: Situations involving risk of self-harm or harm to others may be reported in accordance with applicable policies and laws I may withdraw my consent at any time by contacting program staff Information about the program, its process, and the roles of participating partners has been explained to me I authorize the sharing of personal information (including, where necessary, personal health information) among participating partners for the purposes outlined above This consent is valid for 365 days from the date of signing. I understand that I may withdraw this consent in writing at any time by contacting the program administrator or designated program representative. My informationMy Name(Obligatorio)Fecha de nacimiento(Obligatorio) DD barra MM barra AAAA My Signature(Obligatorio)
