The Peace Corner Youth Center is an after-school and school break program for youth aged 8-18 years old. Youth above 18 still enrolled in high school can enroll on a case by case basis.
PARENT(S)/GUARDIAN(S) MUST COMPLETE THIS FORM THEMSELVES FOR EACH CHILD ENROLLING.
Program policies and procedures are subject to change at the discretion of PCYC management. Your signature confirms that you have read and agree to the statements detailed above.
CONSENT TO SERVICES
Welcome to Catholic Charities of the Archdiocese of Chicago. This Consent to Services form is designed to give you important information regarding services that Catholic Charities provides. Depending on the services you receive from Catholic Charities, you may have certain rights under state and federal laws. Some of these rights are summarized below.
CONFIDENTIALITY: Clinical records of Catholic Charities clients are confidential and are safeguarded as required by law and Catholic Charities’ policies. Clients will receive a “Notice of Privacy Practices” which provides information regarding your rights under HIPAA, 42 C.F.R. Part 2, and state mental health confidentiality laws, if applicable. Disclosure of confidential information is generally made only with your written consent. Exceptions to this policy include, without limitation, the following: (a) When a court orders the release of your records; (b) when there is knowledge of, or reasonable cause to believe, a minor or vulnerable adult is being abused or neglected; (c) when it is believed there is serious, foreseeable and imminent danger of physical harm or violence to you, other identified persons or the community, (d) for quality assurance reviews, licensing, agency accreditation and audit or evaluation by funding bodies, and (e) as otherwise required by law.
E-MAIL: Catholic Charities has established secure measures to safeguard any e-mail you may send to your worker or to the organization. Also, we are unable to prevent disclosures of your information due to errors in transmission or unauthorized acts of third parties.
TELEPHONE & TEXTING: Texting is not a secure form of communication and Catholic Charities is unable to prevent disclosures of your information due to errors in transmission or unauthorized acts of third parties.
CLINICAL RECORDS: Clients have a right to see their own clinical records. If a client is under 12 years old, the client’s parents or guardian may access the records without the client consent. If a client is between 12 and 18 years old, a parent or guardian may see the records in certain circumstances, depending on the services provided.
GRIEVANCES: If you have a concern about the services being provided, or decisions made about you, you (or a parent or guardian if allowed by law) may discuss the matter informally with the director of the program or department involved. You may also file a grievance in writing with the director of the program or department involved. If not resolved, you may send the grievance to the next management level personnel. If the grievance continues unresolved, the grievance may be sent to the Vice President of the Service Area or designee. Lastly, an appeal to the Senior Vice President of Program Development and Evaluation of Catholic Charities may be initiated. A copy of the complete Client Grievance Procedures will be made available upon request.
INDIVIDUALIZED SERVICE PLAN: Clients have the right to adequate care, based on an individual service plan in a setting appropriate for the services involved. The plan shall be formulated and reviewed periodically with the client and/or parent/guardian.
WITHDRAWAL OF CONSENT TO SERVICES: I understand that I have the right to ask questions and to be informed regarding any services in which I am asked to participate. I further understand that while I may withdraw this consent to participate in services at any time, if I do so, my services with Catholic Charities will be terminated immediately.
FOR MENTAL HEALTH/SUBSTANCE ABUSE TREATMENT: I HAVE BEEN INFORMED OF ALL OF THE RISKS AND ANY COSTS ASSOCIATED WITH TREATMENT TO BE PROVIDED, INCLUDING INFORMATION REGARDING THE NATURE OF THE TREATMENT, POSSIBLE ALTERNATIVES TO TREATMENT AND THE POTENTIAL RISKS AND BENEFITS OF TREATMENT.
BY SIGNING BELOW, I INDICATE THAT I HAVE READ THE ABOVE STATEMENTS OR HAVE HAD THEM READ AND EXPLAINED TO ME IN A LANGUAGE WHICH I UNDERSTAND. IN ADDITION I HAVE RECEIVED A COPY OF CATHOLIC CHARITIES’ CLIENT RIGHTS AND RESPONSIBILITIES. I HEREBY CONSENT TO THE PROVISION BY CATHOLIC CHARITIES OF ANY AND ALL APPROPRIATE SERVICES TO ME, OR TO MY CHILD OR WARD.
*In appropriate circumstances, signatories may be requested to furnish identification. Witness has reasonable belief of the identity of the person signing. If additional signatures are needed, use Consent to Services Supplemental Form and staple to this form.
INFORMATION ON A MINOR’S CONSENT TO SERVICESA minor is defined as a person under the age of 18. Staff should consult Agency Policy D-7, Services to Minors, for additional information regarding Services to Minors as this is just a summary of information on a minor’s consent to services.
In general, the consent of a parent or guardian is required for a minor to obtain services. However, There are some exceptions to this, including the exceptions listed below:
A. Substance Use Disorder Care
Minors between the ages of 12 and 18 who are seeking substance use disorder treatment for themselves or who have a family member who abuses drugs or alcohol, may consent to receive health care services or counseling related to the diagnosis or treatment of the substance use.
B. Mental Health Care
Minors between the age of 12 and 18 may consent to confidential outpatient counseling or psychotherapy. If the minor is between the ages of 12 and 17, the outpatient counseling or psychotherapy services shall be initially limited to not more than eight (8) ninety-minute (90) sessions. For additional services without parental consent, please consult Agency Policy D-7, Services to Minors.
C. Victim of Criminal Sexual Assault/ Abuse
A minor may consent to counseling, diagnosis or treatment associated with criminal sexual assault or abuse.
A minor 12 years of age or older may consent to testing, treatment and counseling for HIV/AIDS.
If you have any questions about the information contained in this section, please contact your supervisor and consult with the Legal and Compliance Services Department, as necessary.
(Rev. August 2018)
Clients Rights and Responsibilities
Welcome to the Catholic Charities of the Archdiocese of Chicago. We fulfill the Catholic Church’s role in the mission of charity to anyone in need by providing compassionate, competent and professional services that strengthen and support individuals, families, and communities, based on the value and dignity of human life. As a person who is receiving services, you have the following rights and responsibilities.
You have the right:
You have the responsibility:
By signing your name below, you indicate that you have received, read and understand your Client Rights and Responsibilities.
CONSENT AND RELEASE FOR PHOTOGRAPHS, INFORMATION FILMS OR VIDEOTAPES OF INDIVIDUALS UNDER 18
I do hereby certify that I having the legal right to contract for my child or ward, do hereby agree in his or her name as follows:
I do hereby on behalf of my child or ward, and his or her heirs, wards, executors, and administrators, give, grant, assign and wholly deliver to the Catholic Charities of the Archdiocese of Chicago, all the right, title and interest in any and all photographs, films and/or videotapes of my child or ward, as well as his or her information which the Catholic Charities of the Archdiocese of Chicago or its duly authorized representatives and employees shall make or shall cause or permit to be made, as well as in any and all photographic prints, enlargements or reductions, artwork, drawings, motion pictures, videotapes, animations, retouchings, engravings, written marketing materials or external media stories and other reproductions that the Catholic Charities of the Archdiocese of Chicago, its aforementioned photographic, film, tape negatives or written materials or from any part of them, for the purpose of depicting, publicizing, soliciting funds for, or otherwise illustrating the work of the Catholic Charities of the Archdiocese of Chicago.