Consent for Wraparound Screening

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For questions about filling out this form, please contact wraparound@multco.us or call 503-988-4069.
Behavioral Health
BHD-506 8/25/17

If your youth is involved with multiple systems, they may also be screened for Wraparound through the Wraparound Review Committee with your agreement.

I understand that the screening process may include a review of my youth's records from programs such as those listed below who may or may not have been involved with my youth:

Wraparound Review Committee

DHS Child Welfare Multnomah County Behavioral Health Division
Juvenile Justice Peer Partners at OFSN, NAMI and Youth Era
Portland Public Schools Physical/Mental Health Programs in Portland
Special Education Developmental Disabilities
Oregon Youth Authority

Email *

Program *

Wraparound

Legal Guardian/Parent Name *

Legal Guardian/Parent Email *

Legal Guardian/Parent Phone Number *

Youth Legal Name *

Youth Date of Birth *

YYYY

I consent for my youth to be screened for Wraparound Care Coordination eligibility *

Yes, I consent for my youth to be screened for Wraparound Care Coordination eligibility.

No, I DO NOT consent for my youth to be screened for Wraparound Care Coordination eligibility.

I know that I can refuse to electronically sign this consent for Wraparound Care Coordination screening and that I can withdraw my consent at any time by contacting wraparound@multco.us or calling 503-988-4069 at any time but that actions already taken before I have withdrawn my consent cannot be revoked. I understand that participation in the screening is voluntary and hereby give my consent for my youth to participate in the screening *

I understand and give consent.

I DO NOT understand and DO NOT give consent.

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