Miriam's Heart Client Intake-miriamsheart

Miriam's Heart Client Intake

This form is used to gather general information to provide assistance to adoptive & foster families, child placement, supplies, crisis pregnancy assistance, and other needs of families & children requesting help from Miriam's Heart.

Today's Date

First name

Last name

Contact information

Please indicate a phone number or email where we can reach you. We cannot respond unless we receive at least one of these.

Phone Number

Address

Where are you from?

Tell us about you and your situation

How did you hear about us?

I am already affiliated with Miriam's Heart

Social media (Facebook, twitter, Instagram)

Community (My church, friends, neighbors)

Agency Referral (Adoption agency, DCF, agency, Tri-County, Mobile Response)

Other

Please write a brief description of your needs/family so that we can become familiar with your situation

Choose what best represents you (or the family you are assisting)? please provide us with more information in order that we can best meet your needs (you will be able to select from various types of assistance on the next section)

Considering adoption or foster care

Adoptive family

Foster (Includes relative and non relative kinship) family

Adoptive AND Foster family

Adult adoptee or survivor of childhood maltreatment

Social Worker/Case Manager

Birth parent

Other (not listed)

How can we help?

I need someone to talk to about mentoring/training

I am in process (or already an adoptive/foster family) and looking to connect with adoptive/foster f

I need help with an unplanned pregnancy

I need assistance with child placement/respite support

I am open to an identified adoption

I need in kind support (meals, food, baby supplies, clothing etc)

Something not listed

Are you being helped by any other organizations?

Yes

What is the MOST IMPORTANT thing we can do to help?

Please add any additional information here. If you are requesting assistance with the placement of a child or a foster care need, indicate the case worker name and contact information here.

Is the need emergent? (A child is in imminent danger, or there is a dire immediate need). Emergent requests will be responded to as quickly as possible, however, in the event of an emergency, please call 911 and seek immediate assistance)

Yes, I understand if there is an immediate need, I will also call 911

Waiver, Consent and Hold Harmless

TERMS & CONDITIONS

I understand that I am voluntarily participating in activities and assistance organized by Miriam's Heart, a non-profit organization largely supported by a team of volunteers, and that participation may include but are not limited to care portal, respite, care packages, and other events.

Errors and omissions

I understand and acknowledge that Miriam's Heart is a charitable organization dedicated to supporting individuals and families in need.

I release Miriam's Heart from any liability, claims, demands, or actions that may arise due to errors or omissions in their activities, including but not limited to:

Incorrect information provided during communications.
Inaccurate data entry or record-keeping.
Mistakes or oversights in project management.
Any other errors or omissions related to our collaborative efforts, including but not limited to data breaches and leaks.

The Errors and Omissions waiver is not intended to negate any rights or responsibilities under applicable laws and regulations. It is meant to foster an atmosphere of trust between Miriam’s Heart and families while acknowledging the potential for human error.

Hold Harmless Agreement

I agree to indemnify, defend, and hold harmless Miriam's Heart, its employees, volunteers, agents, representatives, and affiliated entities from any and all claims, liabilities, losses, damages, expenses, or attorney's fees arising out of or related to my participation in the activities, including any claims brought by third parties.

Child Protection Policy

https://docs.google.com/document/d/1oti7QVWcNLTDYxEmPd0T-jPihJiCGf2jpcttj_k6lZA/edit?usp=sharing.

By selecting "Yes" below, you are acknowledging that you have carefully read and fully understand the terms and conditions of this Release of Liability Agreement. You acknowledge that you are freely and voluntarily signing this Agreement, intending to be legally bound by its terms."

Waiver and Release

In consideration of being permitted to participate in Miriam's Heart activities, I hereby waive, release, and discharge Miriam's Heart, its employees, volunteers, agents, representatives, and any affiliated entities from any and all claims, liabilities, demands, actions, or causes of action, whether known or unknown, arising out of or related to any injury, loss, or damage that may be sustained by me or my family members while participating in the activities.

Acknowledgment and Assumption of Risk:

I acknowledge that the activities mentioned above may involve inherent risks, including but not limited to physical injury, property damage, emotional distress, and other potential harms. I understand and voluntarily assume all risks associated with my participation in these activities on behalf of myself and my family members.

I agree to the terms & conditions

Waiver and Hold Harmless Agreement to SHARE INFORMATION

I authorize Miriam's Heart to share information with the Office of the Child Advocate or other related parties to assist in resolving or providing assistance and advocacy for the Participant and their family.

1. Authorization to Share Information

The Participant hereby authorizes Miriam's Heart to share any relevant information, including but not limited to personal, family, and case details, with the Office of the Child Advocate or other related entities deemed necessary to assist in resolving or advocating for the Participant and their family.

2. Release of Liability

The Participant agrees to release, waive, discharge, and hold harmless Miriam's Heart, its officers, directors, employees, and agents from any and all liability, claims, demands, actions, and causes of action whatsoever arising out of or related to any loss, damage, or injury that may be sustained by the Participant, or to any property belonging to the Participant, whether caused by the negligence of Miriam's Heart or otherwise, in the course of sharing information as authorized in this Agreement.

3. No Guarantees

The Participant acknowledges that Miriam's Heart makes no guarantees as to the outcome of any assistance or advocacy provided. The Participant further acknowledges that the sharing of information is intended to assist but may not resolve all issues or concerns.

4. Indemnification

The Participant agrees to indemnify and hold harmless Miriam's Heart from any and all claims, actions, suits, procedures, costs, expenses, damages, and liabilities, including attorney's fees, brought as a result of the Participant's involvement with Miriam's Heart and the sharing of information as authorized herein.

I understand without this authorization, Miriam's Heart cannot take any action on my behalf.

I authorize Miriam's Heart to share information and agree and waive

Yes

No, I understand Miriam's Heart cannot take action on my behalf, but need help with something else

Have you been helped by us before?

Yes

Are you a member of a faith community?

Anything else we need to know?

Your Signature

The detailed intake form: https://www.miriamsheart.org/detailedintake is used after the initial intake to capture detailed information from clients and families. The initial intake (this form) must be filled out and approved prior to the detailed intake form.

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