Family Life Center
Family Life Center
Family Life Center 95 S. Kane Street Kahului, HI. 96732 Phone (808)877- 0880 Fax (808)877-4443
I, , a participant in the Family Life Center’s Programs including but not limited to: Outreach, Ho’olanani Shelter, Housing Placement Programs, Emergency Solutions Grant, Rental Assistance Program, Rapid Re-housing Program, Housing First, and Continuum of Care programs, give my permission for Family Life Center to release any information that this agency has regarding my situation, to any agency, organization, or individual that may have need of this information in order to access services, obtain benefits, or advocate on my behalf.
I also give Family Life Center (FLC) my permission to obtain any information from any agency, organization, or individual that this agency may need in order to manage my case. I further understand that my FLC caseworker may collaborate with other agency caseworkers and/or service providers to avoid duplication of services and to increase case management efficiency.
This agreement will automatically expire twelve (12) months after terminating my participation with Family Life Center’s Programs including but not limited to: Outreach, Ho’olanani Shelter, Housing Placement Program, Emergency Solutions Grant, Rental Assistance Program, Rapid Re-Housing, Housing First, and Continuum of Care Programs.
I understand that you can store any information I have given on this form on your computer and this may be seen by any housing association or agency that offers homes to people on the housing needs register.
I certify that this consent has been given freely, knowingly and voluntarily and that I was able to ask questions about this Consent to Release and Obtain Confidential Information form.
(One form per adult client or unaccompanied youth under 18 with parent or guardian consent)
is an Authorized Agency in Hawaii’s Homeless Management Information System (HMIS) and Coordinated Entry System (CES). The HMIS and CES are shared homeless and housing database systems used by homeless service providers throughout the State of Hawaii. The HMIS and CES improve the ability for you to achieve housing by allowing providers authorized to serve you to share your information. The shared information is used to identify your unique needs and to allow for coordination among different service providers to more efficiently serve you. Sharing your information reduces the need to be asked the same questions repeatedly and may result in faster, more personalized services. The HMIS operates over the Internet and uses many security protections to ensure confidentiality. Additionally, your information is protected by federal HMIS Privacy and Security Standards.
As you receive services, information will be collected from you about the services provided to you, and the differences made as a result of these services.
I give consent for my name and other relevant identifying information to be shared among Authorized Agencies.
I understand that this consent is valid for three years from the date of my signature below and that I may cancel at any time by written request.
Once the HMIS Client Consent Form is completed the form must be uploaded into HMIS and filed at the Agency for seven years.
Revised June 13, 2018
The Family Life Center (FLC) has offered an interpreter at no cost to me, if English is not my primary language.
ENGLISH is my primary language:
YES*
*Sign and date below.
NO
I do not need an interpreter. If you do not need an interpreter go to part 4 and sign below:
I need an interpreter for the following language:
If you need an interpreter, go to part 3, and check the box that applies to you.
I want FLC to provide an interpreter at no cost to me.
I do not want an interpreter provided by FLC, and I will provide my own.
I understand that FLC may secure an independent interpreter to observe my interpreter to ensure the accuracy of the communications.
I understand that the use of family or friends as interpreters may not be the most effective way to help me access the benefits and services that FLC provides.
I understand that FLC does not recommend the use of family members or friends as interpreters and prohibits the use of minors (no one under age 18) as interpreters.
I understand that if I do not want interpreter services at this time, I have the right to change my mind in the future and have FLC provide free interpreter services at that time or bring an interpreter of my choice.
I have read and understand the information on this form. If I have questions or concerns, I can contact the worker listed above.
Family Life Center FFAP:Interpreter Svcs Acceptance/Waiver 2.6.18