ACKNOWLEDGMENT OF SERVICES RELEASE OF INFORMATION FORM
Name of children being interviewed:
I acknowledge the The Children’s Advocacy Center serving Bastrop, Lee, and Fayette Counties (The CAC) will be working with and providing services to my child(ren),
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I understand a video-recorded interview of my child(ren) will be made for the purpose of investigation and that this video-recording is not the property of The CAC. The completed recording is property of the investigating agency or be determined by the Texas Family Code Chapter 264.408 (d).
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I understand any individuals viewing the forensic interview from the observation room are representatives of authorized agencies, represented on the CAC Interagency Agreement and are required to maintain confidentiality as outlined in the Texas Family Code Chapter 264.
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I understand the video-recorded interview will not be used in place of my child’s testimony in court should the investigation result in criminal charges; however, the video-recording may be used in conjunction with my child’s testimony.
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I understand portions of the video-recording may be used for the purpose of training for forensic interviewers, student interns and other child abuse professionals, provided that the portion used will not include the child’s full name.
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If you do not agree for this recording to be used in this manner, please initial here.
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I give permission to The Center staff to contact me following the initial interview to further assess the needs of my family and to send a follow-up survey in order to gather feedback from your experience here at The Center.
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I reviewed the above information, acknowledge understanding of the information and certify all information provided on this form is true and correct to the best of my knowledge. I understand I may request and receive a copy of this form.
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I hereby acknowledge that Children’s Advocacy Centers of Texas, Inc. and my local Children’s Advocacy center (collectively, “CACTX OHCA”) have provided me with a written copy of its Joint Notice of Privacy Practices, which tells me how CACTX OCHA may use or disclose information about me. Not all situations have been described in this Notice; however, I further acknowledge that I have been afforded the opportunity to read this Notice, or have it read to me, and to ask questions about it.
I AM the legal guardian to the child(ren) listed above.
I AM NOT the legal guardian to the child(ren) listed above, but I acknowledge that I am receiving a copy of this form to pass to the legal guardian of the child(ren) listed above.
Name
First Name
Last Name
Relationship to client
Signature
Name
First Name
Last Name
Relationship to client
Signature
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