Family Orientation Questionnaire

    (Please fill in the following tables)

    Which group you want to join?

    Dallas Fort Worth

    Please list all participating family members, including self (adults, teens, children)

    Optional:

    Family Nationality (ies): (Please check appropriate box or boxes)

    Income Level: (Please check appropriate box)

    Adult Form

    Check which one applies:


    Check which one applies:


    Check which one applies to the custody of your children


    What emotions have you been experiencing since the divorce?

    Are you seeing a counselor?


    Are any of your children seeing a counselor?


    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

    Exception #1

    Texas law requires our staff to report to the appropriate government agency any suspected physical, sexual, or emotional abuse or neglect.

    Exception #2

    If we learn that someone with whom we are working has a specific intent to bring harm to him/herself, we reserve the right to inform other family members and/or make appropriate referrals if necessary.

    Exception #3

    If we have reason to be concerned about the drug and/or alcohol use or abuse by a child or teen, we reserve the right to inform the parent.

    Exception #4

    If information is ordered by the court, including a subpoena, we will attempt to contact you about the order. If you oppose the release, the court may nevertheless require compliance with the order.

    Exception #5

    If we learn that someone participating in the program might commit a violent act, we may take steps to protect the intended victim against such danger or inform police, or both.

    Exception #6

    The rights and exceptions to privacy apply to information disclosed in support groups. All group members are encouraged to keep such information confidential, but ChristianWorks for Children cannot guarantee they will do so.

    Exception #7

    At times, ChristianWorks for Children uses case examples of children or teens and their families in publishing articles, conducting professional training, community education, and in fund raising efforts. We may anonymously refer to your situation in those circumstances. Your child, teen or family’s complete name will never be used without your specific written approval.

    Rules for Safety

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

    • Stop Rule: “Stop and I mean it.” When someone is doing something that feels unsafe to anyone, that child/teen needs to stop the activity immediately.
    • Throwing Rule: Throwing soft objects is allowed only. Hard objects may not be thrown anywhere at KidWorks. When objects are thrown, they must hit below the shoulders.
    • Put-Down Rule: No hurting other people’s feelings by making fun of them, name calling or put-downs. Respect each other and self.
    • Hitting Rule: Children/Teens may hit the pillows or stuffed animals, but may not hit another person.
    • Adult Rule: Children/Teens must be with an adult at all times while at KidWorks. They may not leave the building unless accompanied by an adult.
    • Blood Rule: Children/Teens are instructed not to touch blood. In the event that bleeding occurs, children/teens are to tell an adult who will clean up the spill.
    • Privacy Rule: What is said at KidWorks is private and confidential, and stays here (exceptions are state-required reporting laws).
    • I Pass Rule: Children/teens can always “pass” if they do not want to talk.
    • Listening Rule: We respectfully listen to each other, being considerate enough to allow everyone to have an opportunity to talk, if they so choose.

    Help us build healthy homes and families.

    ChristianWorks for Children is a 501(c)(3) non-profit — EIN: 75-1246028.
    With your support, we can continue Jesus Christ’s example of service. Partner with us today!

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