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Safe Teen Assessment Center Parent Disclosure and Authorization

I understand the purpose of the Safe Teen Assessment Center is to assist my child and my family with the situation that brought my child to the LC Valley Youth Resource Center and to connect my child with services that will focus on helping them stay out of trouble in the community, in school, and with my family. I understand the Youth Resource Center has staff that will be in contact with my child and my family to ensure the appropriateness of services and to monitor my child’s progress. I understand that referrals may be made to community providers to further assist my child with their needs.

I understand that all staff at the LC Valley Youth Resource Center will share information of my child’s needs in order to provide me with the most beneficial services, and they will collaborate with my child’s case management.

While at the LC Valley Youth Resource Center, I understand that my child will be asked to participate in a Youth Intake and to complete the LC Valley Youth Resource Center assessments. The information they provide will be kept confidential as much as the law provides. I also understand the LC Valley Youth Resource Center staff are mandated reporters of child abuse and neglect. The LC Valley Youth Resource Center staff will complete a Discharge Summary and include recommendations for treatment based on my child’s interview, the Youth Intake, and the assessments my child completed.

I understand that the Safe Teen Assessment Center is a voluntary program, and the purpose of the Safe Teen Assessment Center is to connect my child with services that will focus on helping them stay out of trouble in the community, in school, and with my family. My child’s participation and honesty in this process are essential for staff to achieve an accurate assessment and to make appropriate recommendations/referrals. By signing this form, I acknowledge that I understand the procedures of the LC Valley Youth Resource Center and that information about my child will be shared among staff. If I do not understand this form, I agree to ask staff any questions I may have so that I understand this form before I sign it.

I authorize the use, disclosure, and/or release of information gathered through my participation in the Safe Teen Assessment Center program, including information from the following agencies: Department of Juvenile Justice Services, District Attorney’s Office, Department of Family Services, Division of Child and Family Services, Division of Welfare and Supportive Services, Division of Public and Behavioral Health, Children’s Mental Health, School Districts, and local law enforcement. I authorize the use, disclosure, and/or release of information to the Safe Teen Assessment Center program for the purpose of my child’s assessment and recommendations and/or referrals for treatment.

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December 13, 2022 4:44 pm PST

Safe Teen Assessment Center Parent Disclosure and Authorization Uploaded by Michelle King - lcvyrc@gmail.com IP 134.49.227.156