Family Ties Inside Out - Lakes Region Community Services

Family Ties Inside Out Registration

Parent / Caregiver Name*
First Last
Parent / Caregiver Date of Birth*
MM slash DD slash YYYY
Contact Phone*
Email*
Address*
Street Address Address Line 2 City State ZIP Code
Child #1 Name*
First Last
Child #1 Date of Birth*
MM slash DD slash YYYY
Child #2 Name
First Last
Child #2 Date of Birth
MM slash DD slash YYYY
Child #3 Name
First Last
Child #3 Date of Birth
MM slash DD slash YYYY
Child #4 Name
First Last
Child #4 Date of Birth
MM slash DD slash YYYY
Child #5 Name
First Last
Child #5 Date of Birth
MM slash DD slash YYYY
How did you hear about this support group?*
- Department of Corrections Staff
- Family Resource Center Staff
- Other
If other, please list
FTIO Support Group Participant Consent*
I, caregiver and/or parent of minor children listed above, hereby consent for the child(ren) in my care, to participate in the Family Ties Inside Out (FTIO) Support Group for children with incarcerated parents, led by The Family Resource Center of Central NH. Description of Services: The purpose of the program is to offer education and support to help children who are dealing with the absence of a parent during and after incarceration. I understand that this Children’s Support group does not provide counseling, but is an educational and support program designed to teach skills, facilitate self-awareness and confidence, promote prosocial behaviors, and demonstrate how to effectively deal with some of the feelings (like sadness, confusion or anger) that children may experience. The group facilitators have found that when working in groups, children gain support from others who are experiencing similar situations or who have adjusted well after experiencing a similar situation in the past. I am also aware that the despite the fact that the group facilitators may be professional counselors, this group will not provide group counseling. Confidentiality: Parents/caregivers are welcome to contact the group facilitator with any questions or concerns. I understand that participation in the group is completely voluntary and confidentiality is addressed and respected. I understand the exception to this is the group facilitator’s legal and ethical responsibility to take appropriate action in the case of an individual intending to do harm to self or others. I give my consent for the facilitator of the children’s support group to consult with other children’s support group leaders and with the FTIO Project Director, a developmental psychologist, to help determine what activities, responses and skills are most beneficial to children attending the group. Children will not be identified by their full names during this discussion.
- I have read, understand, and agree to the above.
2nd consent*
In order to continue grant funding for this group, registration information and attendance will be entered into a database by Family Resource Center of Central NH (FRC-CNH) staff or Family Ties Inside Out (FTIO) project staff. The attendance report is anonymous and all names will be kept confidential. Registration and attendance data will also be used for the purpose of sending out gift cards following participation in groups. We are able to provide a $20 Walmart gift card after every meeting that the registered child attends. In addition, each time a child attends a support group session, he/she will be entered into a drawing for a $100 Walmart gift card to be awarded in September 2021.
- I have read, understand, and agree to the above.