VDSS Data Sharing Consent Form | DePaul Community Resources

Post-Adoption Services Data Sharing Consent

Family Name(Required)

First Last

Case Manager Name

First Last

County

Data Sharing with the Virginia Department of Social Services

Our post-adoption support program is funded by a grant from VDSS. They are asking for your consent to share certain personal information with them for research and to evaluate our services. Sharing your data is optional, and services won’t be affected if you choose not to share. All shared data will be protected by state and federal law. You can withdraw your consent at any time. To change your consent status, contact rpacs@depaulcr.org

PLEASE KNOW THAT SHARING YOUR DATA IS OPTIONAL AND THAT SERVICES WILL NOT BE WITHHELD IF YOU DECLINE TO SHARE YOUR INFORMATION.

VDSS is requesting the following data for each household member:

First name
Last name
Date of Birth
Race
Home address
Adoptive parent email address
Services received (case management, peer support, mental health, training/education, crisis support)
Date of service
Location of service

Consent

*A CONSENT FORM MUST BE COMPLETED FOR EACH PARENT*

My family consents/declines to have their data shared with the Virginia Department of Social Services(Required)

Decline

Consent

Consent For Adopted Children

*ONLY ONE PARENT NEEDS TO PROVIDE CONSENT FOR THE ADOPTED CHILDREN IN THE HOME. INFORMATION FOR BIOLOGICAL CHILDREN DOES NOT NEED TO BE INCLUDED*

DePaul Community Resources has consent to share the personal data of family members listed below, with the Virginia Department of Social Services:

Please list all members of the family whose data can be shared with the Virginia Department of Social Services

Signature of Person Completing This Form

First Name(Required)

Last Name(Required)

Email(Required)

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