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    Consent Form

    Uploaded by

    Jhonalyn Laurio Estrera
    This document is a consent form for a client to allow a handling organization to share their information with other service providers to receive help. The client signs to permit their personal details and incident report to be disclosed confidentially to appropriate assistance sources. If the client refuses to sign, their reasons for denial are noted. The form is stored separately from intake forms to maintain privacy.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Consent Form

    Uploaded by

    Jhonalyn Laurio Estrera
    76 views2 pages
    This document is a consent form for a client to allow a handling organization to share their information with other service providers to receive help. The client signs to permit their personal details and incident report to be disclosed confidentially to appropriate assistance sources. If the client refuses to sign, their reasons for denial are noted. The form is stored separately from intake forms to maintain privacy.

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    Consent Form.docx

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    This document is a consent form for a client to allow a handling organization to share their information with other service providers to receive help. The client signs to permit their personal details and incident report to be disclosed confidentially to appropriate assistance sources. If the client refuses to sign, their reasons for denial are noted. The form is stored separately from intake forms to maintain privacy.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    76 views2 pages

    Consent Form

    Uploaded by

    Jhonalyn Laurio Estrera
    This document is a consent form for a client to allow a handling organization to share their information with other service providers to receive help. The client signs to permit their personal details and incident report to be disclosed confidentially to appropriate assistance sources. If the client refuses to sign, their reasons for denial are noted. The form is stored separately from intake forms to maintain privacy.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
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    CONFIDENTIAL

    CONSENT FOR Client Code: Incident


    RELEASE OF INFORMATION ___________ No:
    __________

    This form should be read carefully and clearly explained to the client.

    I, ___________________________________________________________, give my
    (Name of client or parent/guardian)

    permission for
    ________________________________________________________
    (Handling organization)

    to share information about me and the incident that I reported to them to other
    service providers that they deem appropriate so that I can receive help on safety,
    health and psychosocial, legal, and other needs.

    I also understand that shared information will be treated with confidentiality and
    respect, and shared only as needed to provide the assistance that I need.

    Signature/thumbprint of client: ____________________________


    Date signed: ____________________________

    Note: The parent or guardian will sign the consent form if the client is a child below
    18 or as defined by RA7610.

     Check this box if the client refused to sign the consent form. Indicate reason/s for
    refusal:
    ________________________________________________________________
    ________________________________________________________________
    ________________________________________________________________

    Note: Do not attach the Consent Form for Release of Information directly to the
    Intake Form. It should be stored separately to ensure client confidentiality.
    CONFIDENTIAL

    CONSENT FOR Client Code: Incident


    RELEASE OF INFORMATION ___________ No:
    __________

    Ang form na ito ay dapat basahin nang mabuti at malinaw na ipinaliwanag sa


    kliyente.

    Ako si ________________________________________, binigbigyan ng pahintulot


    (Pangalan ng kliyente o magulang/tagapag-alaga)

    ang ____________________________________________________
    (Organisasyon na may hawak ng kaso)

    na magbahagi ng impormasyon tungkol sa akin at sa mga pangyayari na inulat ko sa


    kanila sa iba pang mga service providers na makatutulong sa aking kaligtasan,
    kalusugan at psychosocial, legal at iba pang mga pangangailangan.

    Nauunawaan ko na ang ibinahagi kong impormasyon ay mananatiling pribado at


    ibabahagi lamang kung kinakailangan at makatutulong sa akin.

    Lagda o thumbprint ng kliyente: ____________________________


    (Petsa): ____________________________

    Paalala: Ang magulang o tagapag-alaga ang lalagda ng consent form kung ang
    edad ng kliyente ay 18 pababa o ayon sa depinisyon ng RA7610.

     Lagyan ng tsek ang kahong ito kung ang kliyente ay tumangging pumirma sa
    consent form. Ilista ang dahilan o mga dahilan ng pagtanggi:
    ________________________________________________________________
    ________________________________________________________________
    ________________________________________________________________

    Paalala: Huwag isama ang Consent Form for Release of Information sa Intake
    Form. Ito ay dapat hiwalay na nakatago upang masigurado ang client
    confidentiality.

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