CONSENT AND CONFIDENTIALITY

I, __________________________________________ ________________________________________ ,
(LAST name) (FIRST name and middle initial)

understand that all notes, records and communications are kept secure and confidential by Catholic

Crosscultural Services (CCS). Information may be shared within CCS for the purposes of case management,

quality assurance and program or service eligibility. I understand that all CCS employees are bound by

strict confidentiality. I am aware that the non- identifying personal information retained by CCS will be

used to produce statistical reports and that these reports will be released to funders, or other institutions

in aggregate form. No personal identification will be disclosed.

Limits of Confidentiality

I also understand that CCS is required by law to report actual or suspected child abuse, or if there is a

significant risk of harm to myself or to other people. Confidentiality is limited by law if a judge orders the

release of information during legal proceedings. Files can be subpoenaed and CCS employees may be

required to testify in court.

Signed on _______________________ day of ____________________________ 20 ___________________

Signature of Client/Parent/Guardian:

Signature of Witness: