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HFA Program Authorization and Consent Form

  1. HFA Program Authorization and Consent Header
  2. I am consenting to participate in the Chisago County Public Health HFA Program. I understand that this is an intensive, long-term voluntary home visiting program. HFA Program goals are to cultivate the growth of nurturing, responsive parent-child relationships; to promote healthy childhood growth and development; and to build the foundations for strong family functioning.
    Chisago County Public Health will maintain a family health record related to health status and services. The reason and intended use for keeping a family health record is to provide my family with comprehensive health services. I understand that I may refuse to answer questions, but this may result in limited services being available to me. Information may be shared through phone calls or reports to my doctor, clinic personnel, social service persons, and/or other persons to the extent authorized by law.
  3. Your private information will not be released to anyone else without your signed consent, unless otherwise authorized by law or court order. Family HFA Program information will be shared with funders, evaluators, and the advisory board as needed without revealing who the families are within the program.
  4. Family Statement of Rights
    ~Have a right to be treated with dignity, with respect, with courtesy and with professional competence. ~Have a right to confidentiality in accordance with all local, state and federal laws. ~Have a right to ask questions about the HFA Program at any time and a right to expect honest, direct and full explanations of our services. ~Have a right to participate in the planning of services to be provided or the right to a family goal plan. ~Have a right to receive referrals, as appropriate to other service providers. ~Have a right to refuse service.
  5. Follow Up Care
    HFA is a voluntary program and you may leave the program at any time. If you decline visits after being in the program and have not graduated, you may re-enter the HFA Program at a later date upon your request.
  6. Mandated Reporter
    We are required by state law to report to Child Protective Services or the local law enforcement agency without consent if we have reasonable cause to believe a child is being maltreated or neglected.
  7. Grievance Policy
    The Metro Alliance for Healthy Families is a collaborative partnership that supports new parents. We are always striving to improve services and ask that you let us know in the event you have a concern, grievance or complaint about the service you receive.
  8. We invite you to speak directly to your Home Visitor about any concerns you may have about the services you receive. We recognize that may not always be possible, and in those circumstances we invite you to communicate with your Home Visitor's supervisor. If you raise any concerns, please be assured that these issues will be addressed in a fair, timely, and respectful manner. You may submit your concerns via phone, e-mail or written correspondence.
  9. Pamela Bates Address Block
  10. By signing this form, I consent to participate in the HFA Program offered by Chisago County Public Health. I understand and agree to the program terms and that my participation is voluntary.
  11. I have reviewed:*
  12. I agree and consent to providing a digital signature.
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