THE MARSH FOUNDATION

Informed Consent

The Marsh Foundation Child and Family Services provides a residential living program for youth who have behavior and/or family problems. These problems are serious enough to require placement of youth away from their home. The placement may last 6 to 12 months or longer depending on the youth’s response to treatment.

Youth who come to The Marsh Foundation Child and Family Services live in group homes operated according to the Ohio Department of Job and Family Services (ODJFS) standards. Up to ten youth may reside in each group home. The workers help youth learn skills so that they may get along better at home, school, and in the community. The youth learn social, academic, pre-vocational, and self-care/independent living skills. Examples of specific skills include cooperation with family members, respecting property of others, and the importance of household tasks. Each youth also participates in academic, vocational, agricultural, and physical education along with moral development.

I have decided that I need to place my child in a residential program. I have chosen placement at The Marsh Foundation so that my child can achieve the goals set by me, my child, and members of our treatment team. I understand this is a voluntary placement and my child and I agree to the conditions described in this consent form.

While my child lives at The Marsh Foundation, I understand that the workers will act as a parent to my child in any way that I would act as a responsible parent. I authorize the exercise of all my parental rights by the staff as long as my child is in The Marsh Foundation residential program. I also agree to work cooperatively in allowing my child to participate in activities at The Marsh Foundation. I will be encouraged to participate in my child’s treatment.

I understand that I will be informed on a consistent basis regarding my child’s status and progress. I understand that my child’s Family-Teachers are primarily responsible for my child’s care and that I may contact The Marsh Foundation with any concerns or questions regarding my child.

I understand that employment, athletic involvement, vocational training, spiritual development, and recreational activities are all facets of The Marsh Foundation Child and Family Services. Examples of these activities include, but are not limited to, learning to use tools, general household maintenance, and campus-wide activities. These campus-wide activities may include, but are not limited to, attending semi-professional ball games, campus gatherings, and school programs. Some of these activities may involve traveling to a neighboring state (i.e. Fort Wayne IN, Decatur IN, or Bluffton IN). My child will be socializing with other youths in the program, the general public, and workers and their families as deemed appropriate according to their service plan.

I also realize that a physical restraint may be used to intervene only when my child poses treatment reasons such as a serious clear threat of personal harm to him/herself or to others or when extensive property damage which may result in injury is imminent. Only trained techniques of passive physical restraint will be used by a qualified person. Qualified persons are those who are trained and have shown competence in the utilization of the passive physical restraint. Passive physical restraint is defined as a trained method of physically restricting a person’s freedom of movement, physical activity or normal use of his or her body, without the use of mechanical restraint devices.

Evaluative practices such as consumer surveys are a routine part of The Marsh Foundation. The information gathered is used to evaluate and improve the effectiveness and quality of services The Marsh Foundation provides. Every effort will be made to prevent any use of this information which may identify my child or my family as dictated by The Marsh Foundation’s confidentiality policies and Health Insurance Portability and Accountability Act (HIPAA) regulations.

I (We) have read each paragraph in this Informed Consent Form. Any questions I had have been satisfactorily answered. I understand the information contained in this Consent Form and by signing below, I agree to the conditions established by this document