PERMISSION TO PARTICIPATE IN SERVICES
BLOOM365's goal is to provide your teen child with individual and/or group advocacy services and emotional support to help improve their safety, healing and well-being. A trained BLOOM365 Advocate will provide your teen child with access to a wide range of victim advocacy services which include: safety planning, information, emotional support, case management and peer support groups.

By completing and submitting this form, you:

1. Agree to your teen child's participation in one or more of the advocacy services outlined below.
2. Understand and agree to the terms and conditions outlined below.
3. Understand that BLOOM365 does not provide psychotherapy or counseling services.
4. Understand that BLOOM365 provides education, advocacy, intervention and training services related to healthy relationship promotion and teen dating abuse, domestic violence, sexual violence, and gender based violence prevention and response.
5. Agree, on behalf of your teen child to fully and forever indemnify, defend and hold harmless BLOOM365 from any and all liability, including any and all demands, claims, damages, losses, injuries, costs (including attorneys’ fees), actions and causes of action (known or unknown) arising out of or related in any way with your teen child’s participation in BLOOM365 Advocacy Services.
6. Understand that information shared by your teen child to the BLOOM365 will remain confidential, unless your teen child discloses information that is considered to be a mandatory report situation. (see Confidentiality & Mandatory Reporting below)

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Email *
By completing and submitting this form.... *
bloom365's Individual Advocacy Services
bloom365's Peer Support Helpline Services
bloom365's Peer Support Group Advocacy Services
Today's Date *
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Parent/Guardian First and Last Name *
Parent/Guardian Address *
City, State Zip *
Phone Number *
Emergency Contact Information (Adult Other Than Parent/Guardian) Name, Phone, Relationship to Teen Child *
TEEN PARTICIPANT INFORMATION
Please complete the following information for the teen child you are giving permission to participate in BLOOM365 Advocacy Services.
Teen Participant First Name, Last Name *
Age of Teen Participant *
ANTICIPATED BENEFITS
As a result of your teen child participating in BLOOM365's Advocacy Services she/he/they may experience one or more of the following benefits:

1. Increased safety
2. Enhanced healing from the trauma of experiencing or witnessing interpersonal violence (teen dating abuse, domestic violence, sexual violence, gender based violence, bullying)
3. Improved well-being such as improvements in self-esteem, coping skills, self-care skills, social connectedness, etc.
4. Validation

CONFIDENTIALITY & MANDATORY REPORTING
BLOOM365 is committed to maintaining the confidentiality of your teen child. Staff and volunteer advocates will maintain confidentiality of personally identifying information for anyone who requests or receives services. Please view our Privacy Policies at www.bloom365.org or by copying and pasting this link into your web browser: https://2b851bc7-dbd0-4d75-af13-b83144119d59.filesusr.com/ugd/6dcd5b_21987e92da0c4ceaa01291cd692999c2.pdf

BLOOM365 advocates, staff and intern volunteers are mandatory reporters and required to report ANY suspected child abuse (physical or sexual), neglect, exploitation or abandonment in a responsible attempt to protect the teen child. This includes any specific threat made that the participant is planning to harm themselves or others.  
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