FAMILY AGREEMENT FORM

Before completing and signing this form, please read and discuss with the adults, children and Teens who want to participate at AdoptionWorks.

1. We understand that AdoptionWorks provides support groups, not therapy or counseling.
2. We understand that although we are not paying for the services of AdoptionWorks a generous donor is. We know that someone is investing in our family and our welfare. We agree to attend regularly. If we miss more than two consecutive sessions (except for illness/crisis), we may be dropped. We agree to call when unable to attend.
3. We agree that children or Teen(s) must always be accompanied and supervised by a parent or another adult for every group meeting. A parent/adult must remain at AdoptionWorks while the child or Teen is in group. Adults may participate in the adult support group.
4. We understand that AdoptionWorks groups are for Adoptees only. Siblings, friends, and extended family members cannot attend group sessions.
5. We understand that while children or Teens are in the same room with parents/guardians, the parents/guardians are responsible for their children’s or Teen’s behavior, not staff. Staff/facilitators are responsible only during private group sessions.
6. We have read and understand the Family Agreement Form. We agree to abide by the guidelines of AdoptionWorks.

Teen Application Form

RULES FOR SAFETY

AdoptionWorks has nine rules developed to ensure the physical and emotional safety of the children and families.

1. Stop Rule: “Stop and I mean it.” When someone feels unsafe, they may ask another person to stop immediately.
2. Throwing Rule: Objects may not be thrown anywhere at AdoptionWorks.
3. Put-Down Rule: No hurting others with words. Respect each other and yourself.
4. Hitting Rule: Hitting pillows/stuffed animals is okay. Do not hit people.
5. Adult Rule: Children/Teens must always be with an adult and may not leave unless accompanied by one.
6. Blood Rule: Do not touch blood. Tell an adult if there's a spill.
7. Privacy Rule: What is said at AdoptionWorks stays private, within legal limits.
8. I Pass Rule: You can “pass” if you don’t want to talk.
9. Listening Rule: Be respectful and give others a chance to speak.

For younger children, these rules are simplified as:

YOUR RIGHTS TO PRIVACY AND EXCEPTIONS TO PRIVACY

Our work with you and your family at ChristianWorks for Children is confidential. Information shared with the staff, volunteers and other participants is private. Your rights to privacy will be strictly maintained. There are, however, some important exceptions to privacy which are explained on the back.

Please read the seven exceptions to privacy on the back before signing below.

In signing this document, I acknowledge that I have had the opportunity to ask questions about ChristianWorks for Children’s Confidentiality Policy. I have read and understand the “Right to Privacy and Exceptions to Privacy” information. I fully understand and accept my rights to privacy and the exceptions to rights to privacy.

SEVEN EXCEPTIONS TO PRIVACY

AUTHORIZATION TO RELEASE INFORMATION
ADOPTIONWORKS SUPPORT GROUP DIRECTORY

An email will be sent to members of the AdoptionWorks group with my contact info to stay connected after group ends.

I understand I may refuse to sign and revoke consent at any time in writing.

PERMISSION FORM

We may use children’s stories, artwork, or quotes for brochures, training, etc. without last names. You will be notified before use.

Your release is valid for one year. You can revoke it at any time in writing. No media use without your written consent.

NON-SUBPOENA CONTRACT FOR ADOPTIONWORKS SUPPORT GROUPS

This contract states that no party shall attempt to subpoena records from AdoptionWorks support groups for any court/legal proceedings.

Support groups are non-clinical and depend on confidentiality and openness. No records or diagnoses are made. Members agree not to use shared information for legal purposes against any party.