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I, ___________________________________________, hereby authorize Rapid Resource for Families staff and contract workers to continue contact with me for the purposes of following up on my childs progress after he/she leaves the Intensive Alternative Family Treatment (IAFT) program. I understand that Rapid Resource for Families will attempt to follow up with me at the following intervals to gather information: 3 months, 6 months, 9 months, 12 months, 2 years, and 3 years after my childs discharge date.
I understand that all responses provided during the follow-up will be confidential and will not affect any current or future treatment that my child or I may request or receive. The purpose of the follow-up is to collect participant information to determine the programs quality and improvement.
For participation in this survey, RRFF will provide an incentive for the time taken to conduct the survey. I understand have the right to decline or accept this incentive by RRFF at my own discretion.
Relationship to youth (please select):
( Self ( Legal Guardian/Parent ( DSS ( Other: __________________
I give consent to contact me in all the following ways (please check all that apply):
( Mail: Please provide address: _______________________________________________
( Telephone: Please provide contact number: ____________________________________
( Email: Please provide email address: ___________________________________________
RRFFs sole purpose is to conduct a follow-up survey related to the youths IAFT treatment post-discharge and the information provided below will not be used for any other intention but for the sole purpose of gathering information and delivering incentives after the survey has been completed.
This consent will remain in effect for 2 years from the date signed. I have the right to refuse to participate and revoke my consent at any time during the follow-up time.
Signature of youth if they are currently 16 is also required so they can be contacted if they age out.
Youth Signature: _________________________________________Date: ____________
Signature: ________________________________________ Date: _________________
Consent for Intensive Alternative Family Treatment Program Follow-Up
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Print
2019-05-17T15:11:58-04:00
2019-05-17T19:11:58Z
2019-05-17T15:11:58-04:00
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