Type - I agree to the confidentiality terms as stated above
Type your full legal name and todays date:
Type your Client ID# assigned by your HOPE Advocate (3-4 digits)
HOPE (Healing Opportunity Provided Equally) Data Privacy/Confidentiality Statement
HOPE keeps a record of information to assist us in helping you. This record will include services provided such as an Order for Protection, group attendance, direct advocacy, referrals and all contacts with other agencies on your behalf. The advocate will also document information in case notes that they feel are relevant to understand your situation. You have the right to refuse to provide information, which may or may not affect the service we can provide.
All of the information you provide to us will be kept confidential. Only people within our organization whose job reasonably requires the information will have access to it. Statistical data, which is considered public, will be gathered from your file but your name will never be used to identify that information. In order for us to release information to another agency or individual you will need to sign a release of information form for each specifìc request for release.
HOPE staff is mandated to disclose information to the proper authorities in the following instances:
1. Physical or sexual abuse of children will be reported
2. Client who threatens to harm themselves or to harm others
3. Pregnant women that are consuming alcohol or other chemicals
4. Physical or sexual abuse of a vulnerable adult as defined by MN Statute 626.557
HOPE believes that you have a right to all information that might affect you, therefore, every effort will be made to notify you prior to release of the above information.
You may request that another agency be given our information to assist them in providing services to you. You will need to sign a release of information form before we would release any information.
You have a right to see all the data that pertains to yourself. You may request to see your information by contacting the staff to set up a time to view it, you will be required to verify your identity and you can see your records without cost. However, if you wish to have copies of records, you might be required to pay a small copying fee.
You have a right to confidentiality, as do the other participants that we work with. You agree to keep confidential the names of other participants involved in the program, any personal information or experiences shared by individual participants or victims, and any confidential information disclosed by staff, volunteers or both.
I have read the above information and I understand my confidentiality rights, the rights of other participants and that HOPE staff are required to report certain information. I understand that if I violate confidentiality, I will be asked to leave the program.