Consent Form

Give your consent

Please complete the client information and consent form below.

The following information describes how the Conflict Resolution Service (CRS) will assist me to make decisions for myself and improve my wellbeing, as part of the Family Tree House program.

I understand that:

For the purposes of this Consent Form, all processes used by CRS are in accordance with the National Mediator Accreditation Standards (NMAS). Consent includes coverage for interviews, conflict coaching, mediation, follow-ups etc.

  • Personal Information

  • DD slash MM slash YYYY
  • 1. CRS Delivery of Services

    I understand that at any time the CRS may choose to:

    • Withdraw from offering services to either one or both parties.
    • Postpone or cancel any stage of the process.

    As far as is practicable, the CRS will discuss the reasons why these decisions may be made by the service and may include, but not be limited to:

    • Health and Wellbeing (including psychological) of party/ies.
    • Additional information being required by party/ies.
    • Party/ies status in relation to the above requirements of Voluntary, Own Decisions and Good Faith has/have changed.
    • Non-payment for services (only where applicable).
  • 2. Voluntary

    I have chosen to engage with CRS voluntarily and of my own free will and can discontinue contact at any time. But if I discontinue contact I am always free to call CRS again for assistance at anytime.

  • 3. Own Decisions

    I am able to make decisions for myself and can choose to agree or disagree to any proposals and ideas discussed during my contact with CRS

  • 4. Role of CRS employees

    CRS staff will not advise me of what to agree or disagree with or give me any advice on how I should think or feel. CRS staff will not make judgements on what I have said or done in the past or any points of view I express.

  • 5. Legal Advice

    CRS cannot advise on any legal matters such as who is right or wrong in the issues I raise, however they are able to refer me for legal advice/information

  • 6. Confidentiality

    CRS will keep all communications had with me confidential, unless…:

    • I agree
    • CRS is obliged to do so by law

    CRS may need to disclose to other agencies or individuals if there is a concern a person’s life, health or property is in serious and/or imminent threat such as:

    • A person makes a threat of violence to physically harm another person
    • A person makes a threat to damage property such as tampering with car brakes, burning down a house

    Specifically for Minors (children & young people)

    • A person discloses child abuse/neglect which can be classed as endangering a child. This includes the child’s exposure to sexual activities, neglect due to carer/guardian being under the influence of drugs/alcohol
    • CRS assess an adult as potentially aiding and abetting a minor to breach a legal order which has been put in place to protect the minor. Agencies that CRS would consider making reports to might be the ACT Policing, Youth Justice, and/or Child and Youth Protection Services (CYPS) etc.

    Before CRS makes a report/disclosure to anyone about what I have said, they will talk it through with me to ensure whether an external report is required, and if so how this might happen

  • 7. Disclosure

    Sometimes other services may want to know how my contact with CRS is going. As with ‘Confidentiality’, CRS will not disclose any details and content of discussions they have had with me except for the reasons under part ‘e’.

    However, CRS may update individuals/services involved in my situation to let them that I am continuing to work with CRS. These updates will only be about processes, not the content – for example, CRS might let a young person’s/my accommodation service know that I have attended an appointment, but CRS won’t tell the accommodation service what was discussed during that appointment.

  • 8. Legal Proceedings

    I am not able to use anything that is said or done during my contact with CRS in any legal proceedings. I will also not involve the staff, mediators, or officers of CRS in legal proceedings.

  • 9. Agreement

    Any agreements made between me and others (eg with my parents) are not legally binding

  • 10. Feedback

    CRS is committed to providing the best possible services for me and my situation. I understand that I am able to give feedback to CRS at any time on what is working for me and what is not; CRS will then be able to make any reasonable and relevant changes. There are many ways I can give feedback to CRS such as face-to-face to any staff member, or in writing (email, SMS etc). At times CRS will also ask me to complete a feedback survey to assist with improving their service

  • 11. National Reporting

    I agree that information about myself can be entered into the Specialist Homelessness Information Platform (SHIP), and CRS will be the only service which has access to my personal information. However, some of my non-identifying information (eg age, nationality, number of contacts) will be used for National Reporting on individuals at risk of, or currently homeless

  • 12. Service Charter

    CRS staff will treat me with respect at all times and will fulfil their professional responsibilities to ensure that my needs are met to the best of their capabilities. Equally, I will treat CRS staff with respect at all times and demonstrate this through my respectful communication and action when I come into contact with CRS staff. Any verbal or physical violence towards staff by me will result in CRS’s withdrawal of services

  • 13. Access to CRS information

    CRS has available for me to access any documents related to this Consent Form, such as NMAS, Service Charter, Feedback/Complaints Mechanism etc. They will either provide this in hardcopy, or I can download from the CRS website

  • 14. Consent

  • Do you consent to be contacted at a later date for survey/evaluation purposes? If you agree, we will know whether you have participated and any information you provide will not affect your current or future service by CRS.
  • 15. Understanding

    I agree that the contents of this form have been explained to me and all my questions at this time have been answered

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