Also, Please Be Advised That DCS Is Required to Report Any Information Related To

Tennessee Department of Children’s Services Child and Family Team Meeting Confidentiality Agreement

During this Child and Family Team Meeting, we ask that all participants respect the family’s privacy. Sensitive issues may be discussed and we want everyone to feel safe to express their opinions or voice their concerns.

DCS has an obligation to keep information related to child abuse or neglect confidential from public disclosure. However, the confidentiality of information shared at a Child and Family Team Meeting cannot be guaranteed. There are circumstances when information discussed may be shared in order to make informed decisions about placement, services, treatment and/or permanency for child(ren). DCS must comply with the request of the court to supply information.

Also, please be advised that DCS is required to report any information related to:

 New allegations or suspicions of the abuse of neglect of a child  If someone threatens to harm himself or herself  If a direct threat is made against another party

Apart from these circumstances, we trust that all participants can agree to safeguard the privacy of this family and what is discussed during the meeting.

Always check the “Forms” Website for most current version and disregard all previous versions. This form may not be altered. Distribution: Child and Family Team Participants and Child’s Case File CS-0624, Rev. 05/07 Page 1 of 2 CFTM Confidentiality Agreement

By signing this confidentiality agreement, I agree to keep all information presented by the other participants of this meeting confidential. I further agree that I will not discuss the contents, purpose, or outcome of the meeting with anyone other than the DCS representatives or the parents or caretakers of the child(ren) at issue. Further, I understand that the release of information regarding this case is prohibited by law, except in certain circumstances determined by DCS.

Participant’s Signature Relationship to Child/Family/Agency Date

Always check the “Forms” Website for most current version and disregard all previous versions. This form may not be altered. Distribution: Child and Family Team Participants and Child’s Case File CS-0624, Rev. 05/07 Page 2 of 2