Model for the Coordination of Services to Children/Youth

Information for Parents/Guardian
Informed Consent

Children/youth and families may receive services from many agencies and service providers to meet their needs. To ensure that your child’s needs are met, service providers will work together with you to develop an Individual Support Services Plan (ISSP). In order to develop an effective support services plan, information about your child will be shared. You will be asked to sign a consent form to permit information sharing. This will allow the support services team to discuss strengths and needs, coordinate service delivery and monitor services to ensure that your child’s needs are met.

	Before you sign this form you should know:
	You have a right to participate in the ISSP process.
	You have the right to privacy.
	If you consent to the sharing of information, your consent must be informed (the person asking you to sign the form will explain the purpose of sharing information)
	You have the right to know what information is to be shared and how the information is to be used.
	You can decide what information will be shared with whom, for what purpose, and to what benefit.
	Only relevant information about your child’s strengths and needs will be shared for the purpose of developing the ISSP.
	You have a right to refuse consent.
	Information will not be shared without your consent, unless the life, safety or well-being of your child or others is at risk.
	You have the right to ask questions before you give consent.
	If you sign this consent form, information about your child’s/youth’s needs will be entered into a data base to be used for regional and provincial service planning and for the development of regional/provincial service profiles. This data will be kept confidential. Information will be shared with service providers only on a need-to-know basis to assist with meeting the needs of your child.

I, __________________________________declare that I am: [please check appropriate box]                       (Name of consenting party)

the parent/legal guardian of__________________________ Who was born on the
    ______day of_____________ , 19______; or

 

I am a minor child, born on the______ day of____________ , 19_____ , who is 16
   years of age or older and who has withdrawn from parental control; or

 

I am 19 years of age or older.

 

I HEREBY GIVE MY PERMISSION to (a) representative(s) of:

   the Department of Health and Community
      Services

    the Department of Justice

    the Department of Human Resources and
      Employment

    the Department of Education

    Other (please specify)

to:    Release/share relevant information with members of the ISSP Team

        Release to_________________________________________________________ , the following             

            information____________________________________________________________________

                           ______________________________________________________________________
                                                       (Describe Information)

        Obtain from_____________________________________________________________________

                            _____________________________________________________________________
                                                        ^{(Identify Department or agency)}

                         the following information__________________________________________________

                            ____________________________________________________________________
                                                         ^{(Describe information - be specific)}

        Complete Child/Youth Profile

which is necessary for the development/implementation of the individual support services plan.

I understand that the information which is the subject of my consent shall be treated as confidential and will only be shared to the extent necessary to develop and/or implement the individual support services plan. This information will only be disclosed in accordance with federal/provincial laws and will not be shared with any other person or agency without my consent except in accordance with such laws and with any interdepartmental protocols on the sharing of information.

This consent is given of my own free will and shall be valid for__________________________________
                                                                                                        (Period of time)

unless withdrawn by me in writing.

_____________________________________________
Date

_____________________________________________
Signature of Consenting Party

_____________________________________________
Witness 

WAIVER OF CONSENT

I___________________________, declare that I am employed by_____________________
       (Name of party)

__________________________________________________________________________________________
                 (Identify dept. or agency)

I met with __________________________on _________________________for the purpose
                         (Identify Individual)                                                       (date)

 
of obtaining a consent to the sharing of information for purposes of the individual support services planning process.

It is my assessment that ____________________________is incapable of appreciating
                                                        (Identify individual)

the nature and consequences of the required consent for the following reasons:

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

I therefore seek approval for the waiver of consent.

______________________________             _________________________________
    Date                                                                 Signature

Approval is hereby given for the waiver of consent to enable information to be shared for the purposes of the individual support services planning process

_______________________________
    Signature of Supervisor