Elevate Program Consent For Services Form

Date*

Name*

First Middle Last

Phone*

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Program/Service Purpose

Catholic Charities is a non-profit social service organization that provides a variety of programs and services to individuals and families. You have applied to the Elevate® program for services. The purpose of Elevate is to help students complete Associates degrees and/or transfer to four-year institutions by helping them overcome their personal barriers to academic success. Please note: Associated Catholic Charities of Baltimore offers a variety of programs and services to strengthen individuals and families and to improve their quality of life. When you apply to Catholic Charities, we consider that you are applying for any or all agency services that may be of help to you. We commit that your identifiable information will be kept within Associated Catholic Charities of Baltimore unless additional consent is received from you.

Service Expectations

The primary services provided by this program are: • Comprehensive service planning and case management to help students identify and enact strategies to overcome individual obstacles to academic progress • Emergency Financial Assistance to help students overcome temporary financial setbacks

Cost: None

This program does not charge fees for the services provided.

Participation Agreement

The primary responsibilities of each student participant are:*

I comply with case management services by meeting with the assigned Support Specialist weekly for face-to-face meetings, either virtually by video chat or in-person, to update service plans and document at least 1 completed action step.

Not every program participant receives the same services; services are determined based on a review of your situation and a service plan developed specifically for you. Your assigned Support Specialist will work with you to develop your service plan.

Rights and Responsibilities*

Select All
I have received a copy of the Client Rights and Responsibilities form for Catholic Charities.
Second My rights and responsibilities were explained to me in language and through a communication method I could understand and I was given the opportunity to ask questions.

Complaints and Grievances*

Select All
I have received a copy of Catholic Charities’ complaint and grievance policy and procedures.
Catholic Charities’ complaint and grievance policy and procedures were explained to me in language and through a communication method I could understand and I was given the opportunity to ask questions.

Additional Information

Legal Guardian Information if applicable*

I understand that services to a minor child or individual unable to provide consent on his/her own behalf require the consent of a parent or legal guardian.

Name of parent/legal guardian, if applicable:

First Middle Last

Additional Rights and Consent*

My right to receive services, through both oral and written communication, in language and through a communication method that I understand has been explained to me. I agree to hold harmless and release Catholic Charities from any responsibility for error due to misinterpretation if at any time I, or a member of my household, decline the language and communication assistance offered by the agency, or choose to have such services provided by an individual of my own choosing.
I understand that my participation is voluntary. I understand that if I initially enroll in Elevate and decide I would no longer like to participate, I am free to withdraw at any time.
I understand that if I have any questions regarding how my information will be collected or used, I can contact Mark Saunders, Program Manager, (667-600-3451, msaunders@cc-md.org).
This consent for services document, and any attachments to this document, were explained to me in a language and through a communication method I could understand and I was given the opportunity to ask questions.
I understand that information about how to contact me may be shared with another Catholic Charities’ program if the agency believes that program may benefit me or my family.
I understand the information contained in this document and by my signature below consent to services as described being delivered to and received by the applicant named above.

Attachments: Choose one, please*

An attachment containing additional information related to your rights and/or requiring your consent is included as part of this document.
There are no additional attachments included as part of this document

Some programs/services provided by Catholic Charities require special consents unique to the program/service. In such cases, additional information will be provided to you as an attachment(s) to this form.

Consenting Party Signatures

Your name here will serve as an official signature.

Signature of Consenting Party*

First Middle Last

Relationship to Applicant*

If it is yourself, please type "Self"

Date*

Support Specialist Signatures

Your name here will serve as an official signature.

Signature of Support Specialist*

First Last

Credentials*

Date*

Interpreter Signatures, if applicable

Your name here will serve as an official signature.

Name

First Last

Date

Inspired by the Gospel mandates to love, serve and teach, Catholic Charities of Baltimore
provides care and services to improve the lives of Marylanders in need.

Elevate Client Consent for Services Form

Program/Service Purpose

Service Expectations

Cost: None

Participation Agreement

Additional Information

Consenting Party Signatures

Support Specialist Signatures

Interpreter Signatures, if applicable