*If you are under 18 years old you must be accompanied by parent or legal guardian.
Informed Consent for Care Appointment
Terms & Conditions of Care Appointment
Privacy: We place a high value on the privacy of the information you may share with us. And, our staff and volunteers function as a team. Therefore, staff and volunteers who are involved in your care may have the responsibility to share your information with each other but only for the purpose of providing integrated care to you; and supervision and accountability for each other.
In some circumstances, including the following, we may be required to disclose your information to third parties:
-Physical Threat: If you threaten to harm either yourself or someone else, we may be required by law to take whatever actions seem necessary to protect people from harm. We also may be required to report to the proper agency any instances in which we believe a child’s or elderly person’s welfare is at risk.
-Legal Proceedings: If you are involved in legal proceedings, we may be required by a court of law to release information about our work together.
Cooperation with other professionals: If we need to share your information with another professional (for example, your physician or therapist), we will first consult you and ask you to sign a consent form.
-Care Appointment Process: During your Care Appointment we will be asking you some questions about you, your family, and your circumstances. You have the right to refuse to answer any question.
Emergencies: Grace Fishers does not provide 24-hour on-call services for problems you may be experiencing. If your emergency is life threatening, you need to visit the nearest hospital emergency room. If you cannot get there on your own, you need to call 911.
My Acknowledgment, Release, Waiver, and Indemnification: I understand and acknowledge that the staff and volunteers of Grace Fishers will consult with me regarding my current situation and will attempt to refer me to appropriate resources. I understand and acknowledge that the staff and volunteers of Grace Fishers do not make any representations or warranties with respect to the results of their consultations and/or referrals or their ability to assist me with my financial, emotional, mental, physical, spiritual or relational management.
I also understand and acknowledge that the staff and volunteers of Grace Fishers could not provide this support ministry without my agreement to the following release, waiver, and indemnification:
-I release Grace Fishers and its directors, officers, employees, agents, and volunteers from any and all liability, and waive all claims, for any liability, injury, loss, damage, or expense that I may sustain as a result of my participation in the ministries of Grace Fishers that are described in this document, unless such injuries and damages result from the gross negligence of Grace Fishers or the individuals mentioned above.
-I indemnify and hold harmless Grace Fishers and its directors, officers, employees, agents, and volunteers (in other words, I agree to reimburse and be responsible for claims made by third parties against Grace Fishers and the individuals mentioned above) in connection with my participation in the ministries of Grace Fishers that are described in this document.
-I further acknowledge that I have read this informed consent (including the acknowledgment, release, waiver, and indemnification), that I am signing it voluntarily, that I am giving up substantial rights by signing it, and that it binds my personal representatives, heirs, beneficiaries, next of kin, and assigns.