Z-Informed Consent & Agreement to Participate in Services Form

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FC Outreach, Inc.

Informed Consent & Agreement to Participate in Services

I,

Name

agree to participate in services provided by FC Outreach, Inc. on behalf of:

Myself,

and Minor Child,

Minor Child Name

The program/services have been explained to me and I voluntarily consent to the program/services.

I have been informed of the benefits, risks, side effects, and alternatives to the planned services.

The services provided may include face-to-face meetings, telephone conversations, and technology-based interactions including video conferencing, email and text exchanges.

I agree to work collaboratively with FC Outreach, Inc., professionals, take an active part in and work toward the outlined goals & objectives in my Families Safety Management Plan.

This consent for services shall be effective on the date of the signature and shall expire one year from the date of signature for ongoing service provision.

Email
Clear Signature

FC Outreach, Inc.
1301 East Gadsden StreetPensacola, Florida 32501

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