Thornwell Home for Children Building Families Program

Consent for Services and Assessment Tools

Your signature below confirms that:

  • You seek services with Thornwell Home for Children Building Families Program until such time as treatment goals are met or other reasons for termination of services have been specified.
  • Your signature indicates that you have the authority to authorize the minor child(ren) to participate in the Thornwell Building Families Program.
  • Your signature also authorizes the Thornwell Home for Children Building Families Program staff to work with other household/family members during the in-home intervention and aftercare period.

______
Parent/Guardian Signature and Date Parent/Guardian Signature and Date
______
Other Adult Participant Signature/Date Other Adult Participant Signature/Date

Informed Consent Statement for PFS, Y-OQ, Y-OQ.SR and P-OQ

Purpose of Evaluation

Thornwell Home for Children Building Families Program is conducting these assessments to make sure that our program is meeting the needs of families in our community. This information is used to guide treatment planning and measure program outcomes.

Participation

The PFS assessment involves asking program participants to complete a survey about your experiences as a parent and your outlook on life in general. The Y-OQ assessment involves asking parents and youth to provide information regarding recent child functioning. The P-OQ measures child functioning for preschool level children. Your participation is voluntary. Your services will not be affected by your decision about participating or your responses on the survey.

Confidentiality

If you choose to participate in this assessment, your identity will be kept confidential. No identifying information will be shared with anyone outside of this program without your written consent. Your information will be combined with all other participants and will never be shared or identified individually without your written consent.

Questions

If you have any questions or concerns about these evaluations, please call Thornwell Home for Children at 864-938-2107.

We hope you will help us by participating in the evaluations. Your participation will allow us to offer and improve services for all families.

□I choose not to participate at this time.

□I agree to participate in the evaluations by responding to the questionnaires.

Parent/GuardianSignature: ______Date: ______

Parent/Guardian Signature: ______Date: ______

Staff signature: ______Date: ______

Revised 11/15/16