SBP-A AUTHORIZATIONS

The following explains the services provided at Kay Phillips Child Advocacy Center (KPCAC) as part of the Sexualized Behavior Problems Program. Please read the authorizations carefully and sign at the end.

Authorization to Release and Exchange Information

The SBP-A program is a community-based program having direct contact and coordination with area agencies involved in the treatment of adolescents with sexual behavior problems. To serve your child and family better, this interdisciplinary process brings together professionals from the fields of child protective services, mental health, juvenile justice, legal, and others. Cooperation and coordination between these area agencies is the key to being able to provide your child and family with quality and efficient service.

By signing below, you indicate your agreement to participate in the interdisciplinary process and grant permission for written and verbal information regarding the child identified below, his or her family, and/or the undersigned, to be exchanged between KPCAC staff and the agencies indicated below for the purposes of screening evaluation, case management staffing, coordination and problem resolution regarding the identified client and family.

The undersigned further authorizes any verbal or written information exchanged as set forth herein to be entered into the KPCAC computerized database(s) and used for research and program evaluation purposes. Any information so used will not identify the client referenced above or his or her family.

The undersigned understands that there are exceptions to the need for the consent contained herein and that such consent is not required in the event there is suspected child abuse or when a person is a danger to himself/herself or others. In such cases, information may be provided to the Department of Social Services, law enforcement or a mental health agency without the consent of the undersigned.

Authorization for Evaluation, Treatment and Research

The undersigned authorizes the KPCAC and its professional staff to conduct a pre-service assessmentand case managementstaffing as deemed necessary.

As part of this screening evaluation, the undersigned understands that his or her child, as well as the undersigned, may be asked to complete questionnaires or surveys, which may be used to determine treatment needs and/or to establish best standards of practice through research and program evaluation. Any information collected by the KPCAC and used for research or program evaluation will be de-identified and kept strictly confidential.

Legal Guardian Intent to Participate

By signing, the client’s legal guardian agrees to participate in the evaluation process and/or treatment services focused on the identified client below. The undersigned understands that any information that he/she gives may be included in the client’s record and disclosed as allowed by law.

Notice of Privacy Practices Receipt and Acknowledgement of Notice

The undersigned hereby acknowledges that he/she has received and has been given an opportunity to read a copy of Kay Phillips Child Advocacy Center Notice of Privacy Practices. The undersigned understands that if he/she has any questions regarding the Notice or his/heror his/herchild’s privacy rights, he/she can contact the KPCAC(843) 875.1551.

Informed Consent:

Consent and authority is hereby given to Kay Phillips Child Advocacy Center and it’s professional staff to conduct a screening evaluation and case management staffing as deemed necessary or advisable by appropriate members of the SBPMulti-Disciplinary Team (MDT).

The following are collaborators in the SBP Program which constitutes the Multi-Disciplinary Team (MDT) described above, and with whom the signee(s) authorizes Dorchester Children’s Center to share information for the purpose of treatment and service coordination:

Additional Informed Consent for Other Agency Involvement:

For the purpose of service and treatment coordination, I hereby authorize The Kay Phillips Child Advocacy Center to RECEIVE/RELEASE information from/to:

A photocopy of these authorizations shall be considered as effective and valid as the originals. These authorizations are valid for two years from date of signature. BY SIGNING BELOW THE UNDERSIGNED REPRESENTS THAT HE/SHE HAS READ AND UNDERSTANDS THE AUTHORIZATIONS CONTAINED HEREIN AND IS KNOWLINGLY AND WILLINGLY AUTHORIZING THE ACTIVITIES DESCRIBED HEREIN:

Signature of Adolescent Consumer*
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Legal Guardian Signature
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Legal Guardian Signature
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Date: 04/28/2025

If you are signing as a personal representative of an individual, please describe your authority to act for the individual (Power of Attorney, DSS designated protector per DSS Safety Plan, notarized agreement, court order, etc.):

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