Family Resource Handbook

FAMILY RESOURCE HANDBOOK AND SERVICE AGREEMENT

Organization Name:     Family/Primary Caregiver Name:

Program/Service Location:     Effective Date:

RECITALS

WHEREAS, Organization provides family support, referral, education, and resource coordination services to families to promote child well-being, family stability, and access to community supports; and

WHEREAS, Family seeks to receive those services and acknowledges the responsibilities and expectations set forth in this Handbook and Service Agreement; and

WHEREAS, the parties intend by this instrument to set forth the scope of services, payment terms (if any), confidentiality obligations, and operational policies governing the provision of services to the Family.

SCOPE OF SERVICES

Services provided may include, but are not limited to: case management, connection to community resources, family education workshops, referral to specialized providers, and periodic assessment of family needs. Services will be provided in accordance with professional standards and applicable law.

PAYMENT TERMS

Fee Amount (if applicable):

Late Fee:    (Applied after a missed payment beyond agreed schedule; may be stated as fixed amount or percentage per billing cycle.)

TERM AND TERMINATION

Term Commencement Date:     Term End Date (if applicable):

Either party may terminate this Agreement without cause by providing written notice to the other party not fewer than days prior to the intended termination date.

CONFIDENTIALITY

Organization shall treat information concerning the Family and household members obtained in the course of providing services as confidential, and shall not disclose such information except as authorized by the Family in writing, required by law, or to provide services described herein. Confidential information includes case records, assessment information, medical and educational records, and personally identifying data.

Exceptions to confidentiality include: (a) disclosures required by mandatory reporting laws for abuse or neglect; (b) disclosures necessary to prevent imminent harm; and (c) disclosures pursuant to valid court order. Organization will seek family consent for releases whenever practicable.

Consent to share limited information for administrative and reporting purposes:
I consent to the sharing of de-identified or aggregated data for program evaluation and funding reporting.
I consent to the release of identified information as specifically described in a separate signed release.

EMERGENCY CONTACTS & HEALTH INFORMATION

HEALTH AND SAFETY; MEDICATION

Families must disclose any health conditions that may affect service delivery. Administration of medication by Organization personnel requires a separate signed Medication Authorization form where Organization agrees to follow written instructions from a licensed prescriber and to document each administration.

Acknowledgement of receipt of Health & Safety policies:
I acknowledge receipt of Organization's Health and Safety policies and agree to comply with them.

PRIVACY, RECORDS RETENTION, AND DATA USE

Organization will retain case records for the period required by law and program policy. Families have the right to request access to their records, subject to redaction of third-party information and applicable exemptions. Requests must be made in writing to the program's records custodian.

GRIEVANCE PROCEDURE

If Family has a complaint regarding services, Family should first attempt to resolve the matter with the assigned staff. If unresolved, Family may submit a written grievance to the Program Director. Organization will respond to formal grievances in writing within 30 days and will provide an appeal option where warranted.

GOVERNING LAW; ENTIRE AGREEMENT

This Agreement and Handbook shall be governed by and construed in accordance with the laws of the state in which Organization is located. This document, together with any attached exhibits or signed releases, constitutes the entire agreement between the parties with respect to the subject matter herein and supersedes all prior understandings, whether written or oral.

Any modification to this Agreement must be in writing and signed by both parties. If any provision of this Agreement is held invalid, the remainder of the Agreement will remain enforceable.

ACKNOWLEDGMENT

By signing below, the parties acknowledge that they have read and understand the policies, disclosures, and obligations described in this Family Resource Handbook and Service Agreement, and agree to abide by its terms for the duration of services.

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