I understand that Kay Phillips Child Advocacy Center (KPCAC) is an interdisciplinary program having direct contact with area agencies involved in the protection of children. To better serve children and families, the interdisciplinary process brings together professionals from the fields of child protective services, mental health, medical, education, legal, law enforcement, and others. Cooperation and coordination between the area agencies responding to alleged child maltreatment is key to KPCAC’S ability to provide optimal service to clients and families. In order to ensure cooperation, KPCAC developed memoranda of agreement (MOA) outlining the specific response guidelines, roles and responsibilities of each agency. A list of these agencies is printed on the back of this page.

I also understand that there are exceptions to the rule for which written consent must be obtained. These exceptions include suspected child abuse or when a person is a danger to him/herself or others. These situations may require involving the Department of Social Services, Law Enforcement, or a Mental Health agency and these contacts are required by law and do not require consent.

By signing this form, I grant my permission for written and verbal information to be exchanged between KPCAC staff and agencies which have signed MOA’s for the purpose of evaluation, treatment, follow up, coordination, and problem resolution with reference to the identified client and family. I understand this may include mental health records covered under the Health Insurance Portability and Accountability Act of 1996 (HIPPA), 45 C.F.R., Parts 160 and 164. If representatives from agencies not listed on the back of this form are present during the case management interdisciplinary process, each participant will have signed a statement of confidentiality and is bound by laws of confidentiality.

Each person seen as part of the identified client’s forensic interview and/or treatment shall sign below. By signing, participant(s) and/or participant’s legal guardian(s) agree to voluntarily participate in the interview and/or treatment services focused on the identified client. The undersigned also understands that any information that he/she gives may be included in the client's record and disclosed as allowed by law. For the purpose of providing quality forensic interview(s) and treatment services to my family, I authorize KPCAC to record the forensic interview and/or treatment of the client identified below. Due to circumstances surrounding the COVID-19 pandemic, I understand KPCAC is utilizing Zoom Video Communications to record the forensic interview. This is in addition to KPCAC’s standard audio/video recording. Furthermore, all known precautions and safety measures have been taken to ensure client confidentiality

I hereby acknowledge that I have received and have been given an opportunity to review a copy of the KPCAC Notice of Privacy Practices.

A copy of these authorizations submitted by email, fax, photocopy, or by any other electronic measure shall be considered as effective and valid as the originals. This consent is valid for two years from the last date of the forensic and/or clinical service

Currently, KPCAC has signed Memoranda of Agreement with the following agencies in the tri-county area:

Dorchester County Agencies:
Dorchester County Department of Social Services
Dorchester Department of Juvenile Justice
Dorchester/Charleston Department of Mental Health
Dorchester Alcohol and Drug Commission
Dorchester District II School District
Dorchester District IV School District
Dorchester Guardian Ad Litem
Charleston/ Dorchester Department of Mental Health
Dorchester Department of Disabilities and Special Needs
Dorchester County Sheriff’s Office
Harleyville Police Department
Ridgeville Police Department
St. George Police Department
Summerville Police Department
Dorchester County First Steps

Berkeley County Agencies:
Berkeley County Guardian Ad Litem
Berkeley County Department of Social Services
Berkeley County Department of Juvenile Justice
Berkeley County School District
Ernest E. Kennedy Center
Callen- Lacey Center for Children
Berkeley County Citizens
Berkeley County Sheriff’s Department
Goose Creek Police Department
Hanahan Police Department
Monks Corner Police Department
Berkeley County Department of Mental Health

Charleston County Agencies:
Dorchester/Charleston Department of Mental Health
Charleston Department of Social Services
Dee Norton Children's Advocacy Center
Charleston County Sheriff’s Office

Tri-County Agencies:
Carolina Youth Development Center
South Carolina Department of Health and Environmental Control-Trident Public Health District
North Charleston Police Department
MUSC Department of Pediatrics
MUSC National Crime Victims Research and Treatment Center
MUSC Department of Psychiatry and Behavioral Sciences Medical Center
My Sister’s House
Parents Anonymous of SC
People Against Rape
Palmetto Behavioral Health System
Lowcountry Equine-Assisted Psychotherapy
Continuum of Care
Palmetto Youth Connections

Other Agencies:
Calhoun County Department of Social Services
Orangeburg Department of Social Services
Cottageville Police Department
Department of the Air Force, Office of Special Investigations
Orangeburg County Sheriff’s Office
Navy Criminal Investigative Services, Charleston
Hope Haven of the Low Country
Thornwel
First Circuit Solicitor’s Office
Ninth Circuit Solicitor’s Office
Colleton County DSS
Florence Crittenton
628th Medical Group, Family Advocacy Program
Windwood Farm Home for Children and Windwood Family Services
Carolina Pediatric & Carolina Teen Center
Colleton Co. Sheriff’s Department
Golden Care Solutions LLC
HALOs
Lakeside Family Center

By signing below, the undersigned represents that he/she has read and understands the authorizations contained on pages 1 and 2 and is knowingly and willingly authorizing the activities described herein. I understand that I may revoke this authorization at any time (except to the extent that action has been taken in reliance on it) by completing a KPCAC Revocation of Consent form.

Kay Phillips Child Advocacy Records Policy

Due to the delicate issues surrounding child physical and sexual abuse, the Kay Phillips Child Advocacy Center wants to ensure that safeguards are held regarding duplication and access to the personal and sensitive information these children are sharing. Therefore, please be advised:

Client mental health records at Kay Phillips Child Advocacy Center (KPCAC) are protected under HIPPA regulations and South Carolina Code §44-22-100 and §19-11-95, including information directly or indirectly identifying a client or former client. We are prohibited from providing these records without a court order signed by a judge or written consent of the legal guardian. The legal guardian must sign a Kay Phillips Child Advocacy Center Release of Information. If the parents are divorced or separated, KPCAC must receive a copy of the court order granting legal custody to the signing party.

Client forensic interview records are considered evidentiary and an authorization to release records is not sufficient for disclosure without a court order signed by a judge, to include language that protects the confidentiality of the minor child’s records. Once these documents are received, the Forensic Interview Report will be released and we will make arrangements for the recorded interview to be viewed via an encrypted web-based system, which will be time sensitive and require a login and password provided by the Kay Phillips Child Advocacy Center.

In regards to medical records, Medical University of South Carolina (MUSC) examinations or other services provided by MUSC at the Kay Phillips Child Advocacy Center must be obtained through the Medical University of South Carolina medical records department.

Protective Order Language to be included in Court Order

As part of KPCAC’s continuous effort to maintain client confidentiality, please provide a court order signed by a judge, to include, but not necessarily be limited to the following items:

• That the records not be reproduced except when authorized by Court Order.
• That the records be viewed or disclosed only on specified terms and conditions.
• That the records be sealed and only opened by Court Order.
• That the Order be applicable to counsel for all parties and any agent or representative of a party.
• That the Order should include signatures executed by counsel for all parties, to include the Kay Phillips Child Advocacy Center Attorney.
• Regarding forensic interview records, counsel for all parties shall receive a copy of the forensic interview report, as well as access to view the forensic interview via a protected web-based online viewing system.
• That the records released pursuant to this Order be returned to the Kay Phillips Child Advocacy Center upon completion of the matter that caused the production of such records.
• Any person who fails to obey the conditions of the Protective Order shall be punished for Contempt of Court.