Forms

Family Rights, Responsibilities and Confidentiality Policy

Program Description:

Healthy Families NSV is a family support program designed to support new parents, share information about child development and parenting, and provide information and referrals to families of infants and young children. Home visits are scheduled at each family’s convenience. Healthy Families staff will: share information and activities related to your child’s age; help you learn to read your baby’s cues; check to see if your child is developing on target; work with you to identify areas where you might want additional support; join with you to complete safety checklists to keep your home healthy and safe for you and your family; and check in with you to make sure our services continue to meet your needs.

Family Rights and Responsibilities:

Healthy Families NSV staff recognize that families are crucial in the lives of children. Healthy Families NSV uses the following policies and procedures so that your rights are protected. All families participating in the program have the following rights:

The right to be treated respectfully by staff who appreciate your culture, beliefs, and values;
The right to end services at any time, since participating in Healthy Families America is always voluntary;
The right to confidentiality of your records;
The right to ongoing participation in the planning of services you receive;
The right to decline to participate in any research, if applicable;
The right to access, upon request, one’s own records;
The right to referral to other services, when needed;
The right to share any concerns you have about services you are receiving by contacting your Family Support Worker’s supervisor at _______________________________;

Confidentiality:

Why do we gather written information?
To document our time together
To support you to develop a written, individualized goal plan to meet your interests
To document progress
How do we keep information confidential?
Records are kept in a locked file.
Records cannot be removed from office areas unless they are signed out for a specific purpose.
Information is shared only on a need-to-know basis with appropriate staff, consultants, and other professionals.
Who can see your records
Appropriate staff members of Healthy Families;
Consultants on a need-to-know basis;
You can see your own records, but not those of others.
How do we use your confidential information?
To review your family’s interests in areas of health, social services, and education or training;
To make reports to our funders, evaluators or researchers (Information or data is shared without your name being included. Personal information is only shared with your signed consent);
To work cooperatively, on your behalf, with other agencies (you will sign consent forms to allow this exchange of information with health professionals, consultants, etc.)
Are there times when we would share information about you without your permission?
If we have reason to believe any child is being abused or neglected, we are required by law to report to the Child Welfare Department.
Such referrals are made so families can receive additional support to help keep their children healthy and safe.

Grievance Report

Date of report(Required)

Name of participant(Required)

First Last

Person completing this form(Required)

First Last

1. Problem/complaint:(Required)

2. What affect did this have on you?(Required)

3. Name of Employee involved:(Required)

4. Your FSWs name(Required)

5. Date it happened:(Required)

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Satisfaction Survey

How Are We Doing

Healthy Families Northern Shenandoah Valley is continually trying to improve our services to families. Typically that means doing home visits and activities with you and your child(ren) in your home. However, the Corona virus (COVID-19) has forced us to make some changes and we are not able to provide “IN-HOME” services at this time. This is for your safety and all the other families in our program. We are not sure how long these changes will be implemented and want you to know how much we miss you! At HFNSV we still want to know what you think and feel about how we are doing-whether it is in your home, or by phone, Doxy.me, ZOOM, Facetime or other platforms. Please take a few moments to complete the following survey. Thank you.

1. Is Healthy Families being supportive to you and your family?(Required)

Yes

Comments

2. How much support have you gotten from Healthy Families?(Required)

A great deal	Some	Not Much	Not Needed

Comments

3. Would you recommend Healthy Families to a friend?(Required)

Yes

Comments

4. How often does your Family Support Worker (FSW) meet with you? (by phone or other method during this Corona Virus/Covid-19 pandemic?(Required)

Comments

5. On average, how long do you “meet” each time?(Required)

6. Are there difficulties when scheduling visits with your Family Support Worker?(Required)

Yes	No	Sometimes	Most of the time

7. Are you and your family treated with respect and consideration?(Required)

Yes	No

8. Are you able to communicate with staff in the language of your choice?(Required)

Yes	No

9. My FSW is interested in learning and understanding more about my family and me.(Required)

Yes	No

10. My FSW makes an effort to include my baby’s father, or my boyfriend/husband in the visits by asking about him, bringing materials for him and/or inviting him to the visit.(Required)

Yes	No

11. I am comfortable sharing personal information with my FSW.(Required)

Yes	No

12. I am comfortable asking my FSW questions about parenting.(Required)

Yes	No

13. My FSW understands how I learn best and I understand the materials she sends/ reviews with me.(Required)

Yes	No

14. My FSW answers my questions or finds answers for me.(Required)

Yes	No

15. Do you feel that your FSW listens to and supports you?(Required)

Yes	No

16. Which words describe your home visitor (please check all that apply)?(Required)

17. Does your FSW know about and refer you to resources in your community (DSS, Child Support, housing, Health Department, C-CAP, etc)?(Required)

Yes	No

18. How would you rate the parenting materials, handouts and activities used during visits?(Required)

Useful	Somewhat useful	Not useful at all

19. How often does your FSW talk with you about parenting, your baby, and his/her health and development?(Required)

Every visit	Some visits	Rarely during visits	Almost never

20. Which areas of your life have improved since beginning the program? (Please check all areas that apply to you)(Required)

21. Overall, how satisfied are you with the help you’ve received from your home visitor?(Required)

Very satisfied	Satisfied	Dissatisfied	Very dissatisfied

22. Have you ever attended a Healthy Families event in the past? (These are temporarily suspended due to COVID-19) We hope someday soon we can meet again in a larger group setting(Required)

Yes	No

If no, why?

23. What did you like about the event(s)?

How could we improve the event(s)?

24. Please name the two things that you like BEST about the Healthy Families program?

25. What do you like LEAST about the Healthy Families program?

26. Please tell us your ideas for program improvement. Include any ideas you might have.

Your FSW’s Name:(Required)

Date(Required)

Your Name (optional):

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Consent to Release Information

Permission

Permission is hereby given to Healthy Families Northern Shenandoah Valley to release information concerning myself and my family to the agencies and individuals listed below. This consent will also authorize the named agencies and individuals to release information to Healthy Families Northern Shenandoah Valley.

Agency(Required)

Individual(s)(Required)

Verbal Consent(Required)

Date(Required)

Signature(Required)

Date(Required)

Witness(Required)

Date(Required)

This consent will remain in effect for 12 months from date of last signature. This consent is also subject to cancellation upon my written request, as of the date the request is received by Healthy Families Northern Shenandoah Valley.

Date(Required)

CAPTCHA

Forms

Family Rights, Responsibilities and Confidentiality Policy

Program Description:

Family Rights and Responsibilities:

Grievance Report

Satisfaction Survey

How Are We Doing

Consent to Release Information

Permission

540-536-4113

301 North Cameron St, Ste 101

9:00 AM - 4:30 PM

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