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Consent and Referral forms

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Notice of Privacy Practices for Mental Health Services

Parent/Guardian Consent Form for See the Girl: In Elementary
Parent/Guardian Name(Required)
Girl's Full Name(Required)
Girls Home Address(Required)
MM slash DD slash YYYY
Grant or Deny Permission
I, the undersigned, do herby grant grant or deny permission to the Delores Barr Weaver Policy Center for the following:
To use the image of my child, and Their grade and age, as marked by my selection below. Such use includes the display, distribution, publication, transmission, or otherwise use of photographs, voice recording, and/or video taken of my child and/or family for use in materials that include, but may not be limited to, printed materials such as brochures and newsletters, videos, and digital images such as those on the Delores Barr Weaver Policy Center’s website: www.seethegirl.org.
To release information about my child’s individual needs to a referral agency such as (Full ServiceSchools, Girl Scouts) if eligible to receive additional services and supports to increase her success. This may include your child’s name, date of birth, needs she is demonstrating, as well as your contact information.
To provide reporting information to the Florida Department of Juvenile Justice Prevention Web system (JJIS) on the demographics and needs of girls served through the It’s Elementary program as per grant requirements. All information will be confidential.
To access the school records of my child and allow use of the information for grant reporting purposes in order to provide information including number of absences and suspensions of all girls served to funders, such as the Department of Juvenile Justice. All information will be kept confidential.
To learn and share more about the needs of girls and the impact of the Policy Center services by using girls’ individual statements in whole or in part. No personal data will be shared and all statements will be anonymous. This means no names or other identifying information will be used.
MM slash DD slash YYYY
I acknowledge that I understand and agree with the Youth Rights Policy and Rights and Grievance Procedure provided to me by the Delores Barr Weaver Policy Center.
Parent/Guardian Consent Form for See the Girl: In the Middle & Groups
Parent/Guardian Name(Required)
Girl's Full Name(Required)
Girls Home Address(Required)
MM slash DD slash YYYY
Grant or Deny Permission
I, the undersigned, do herby grant grant or deny permission to the Delores Barr Weaver Policy Center for the following:
To use the image of my child, and Their grade and age, as marked by my selection below. Such use includes the display, distribution, publication, transmission, or otherwise use of photographs, voice recording, and/or video taken of my child and/or family for use in materials that include, but may not be limited to, printed materials such as brochures and newsletters, videos, and digital images such as those on the Delores Barr Weaver Policy Center’s website: www.seethegirl.org.
To release information about my child’s individual needs to a referral agency such as (Full ServiceSchools, Girl Scouts) if eligible to receive additional services and supports to increase her success. This may include your child’s name, date of birth, needs she is demonstrating, as well as your contact information.
To provide reporting information to the Florida Department of Juvenile Justice Prevention Web system (JJIS) on the demographics and needs of girls served through the It’s Elementary program as per grant requirements. All information will be confidential.
To access the school records of my child and allow use of the information for grant reporting purposes in order to provide information including number of absences and suspensions of all girls served to funders such as (the Department of Juvenile Justice). All information will be kept confidential.
To learn and share more about the needs of girls and the impact of the Policy Center services by using girls’ individual statements in whole or in part. No personal data will be shared and all statements will be anonymous. This means no names or other identifying information will be used.
MM slash DD slash YYYY
I acknowledge that I understand and agree with the Youth Rights Policy and Rights and Grievance Procedure provided to me by the Delores Barr Weaver Policy Center.

Referral Form for See the Girl: In the Community & Open Doors serving victims of sex trafficking

I am referring myself.

Click here to refer yourself
My First & Last Name(Required)
MM slash DD slash YYYY
Address(Required)
If referred person does not have stable housing, please list zip code or county of temporary residence.
Please select the county you live in. Are you homeless or living in a shelter.
  • I am currently homeless
  • I live in a shelter
  • I have a history of homelessness
  • I do not have a history of homelessness
Which program are you referring yourself to?
Are you in need of? (check all that apply)
  • Care Management
  • Survivor Mentorship (for those at risk, or survivors of, Human
Trafficking/Commercial Sexual Exploitation)
  • Counseling
  • Advocacy
  • Other
Are you in involved in the Child Welfare System?(Required)
Are you in involved in the Juvenile Justice, or Justice System?(Required)
Substance Abuse History(Required)
Runaway(Required)
Employment(Required)
School attendance(Required)
Briefly describe the reason for seeking services with the Delores Barr Weaver
MM slash DD slash YYYY

I am referring someone else.

Click here to refer someone else
Name of the person/agency making the referral(Required)
All fields listed below are for the person you are referring.
MM slash DD slash YYYY
Referred Person's Address
If referred person does not have stable housing, please list zip code or county of temporary residence.
Please select the county referred person lives in.
Which program is this person being referred to?(Required)
Is this person experiencing homelessness?
  • Currently experiencing homelessness
  • Currently living in a shelter
  • Has a history of homelessness
  • Does not have a history of homelessness
Is this person in need of (choose ALL that apply)
  • Care Management
  • Survivor Mentorship (for those at risk, or survivors of, Human Trafficking/Commercial Sexual Exploitation)
  • Counseling
  • Advocacy
  • Other
Is this person involved with the Child Welfare System?(Required)
Is this person involved with Juvenile Justice, or Justice System?(Required)
Substance Abuse History(Required)
Runaway(Required)
Employment(Required)
School Attendance(Required)
Briefly describe the reason for seeking services with the Delores Barr Weaver
MM slash DD slash YYYY

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