In Full Bloom Professional Disclosure Statement

Bloom Upstate is a non-profit organization who mission is to support and mentor at-risk-girls and their families in Spartanburg County who are without an active father. The vision of the organization is creating an atmosphere where all girls feel valued and encouraged by adults who actively invest in them. Bloom Upstate is a non-profit organization that is supported and funded by grants and donations. Bloom Upstate is a non-profit organization that provides mentorship, family services, peer group, tutoring, and other support services. Below are the following programs offered by Bloom Upstate:

Mentorship

Bloom Upstate matches at-risk youth ages 12-21 with professional mentors to help young women blossom into mature women to be productive members in society. The mentorship is design to build self-esteem, develop positive peer relationships, develop life and vocational skills.

Tutoring

Bloom Upstate provides personalized tutoring as needed. The organization provides tutoring services provided by certified teachers that will work closely with school staff regarding the girls academic needs. Certified Teachers will be available once weekly and on an as needed basis.

Peer Group

Bloom Upstate offers enrichment sessions through peer groups session offered through the Girl Circle and Sihle program. The programs are aimed at providing an emotionally safe setting that allows the girls to be authentically themselves and use their voices about the things that are important. The peer group program is designed to educate the girls about healthy relationships, decision-making, critical thinking, effective communication, and self care.

Therapy and Family Services

Bloom Upstate offers therapy and family services on a referral basis. The program is identified through Bloom’s Upstate intake process. Therapy Services are provided by Licensed Professional Therapists. In the event, in the assessment, the therapist is unable to provide services within the therapist scope of practice. The therapist will make the appropriate referral to an agency or private practitioner.

Bloom Upstate is an organization that complies with federal, state and local laws. The following topics below explain in event abuse and neglect, confidentiality, duty to warn and protect where Bloom Upstate shall report to the appropriate authorities.

Privacy and Confidentiality

Content of all peer groups and therapy sessions are confidential. Both verbal information and written records (electronic or verbal) cannot be shared with another party without your written consent, or written consent of your legal guardian. If you opt to use electronic communication such as email, faxing and mobile phone text messaging to transmit information relating to the schedule of a group and therapy session or other activities provided by the organization, electronic communication is not generally secure. The confidentiality form will have an option what method of contact you would like to use.

If a court of law or other legally authorized entity orders me to disclose confidential or privilege information without your consent. I will protect confidentiality during legal proceedings to the extent permitted by law. Additionally, I would request that the court withdraw the order or limit the order as narrowly as possible or maintain the records under sealed, unavailable for public inspection.

Duty to Warn and Protect

I am a mandated reporter by law. If you disclose that you have intentions to harm another person, I am required by law to warn the intended victim and report this information to legal authorities. If you disclose or imply to me a plan for suicide, I am required to notify legal authorities and make reasonable attempts to notify your family and any person (s) listed on your emergency contact information.

Abuse and Neglect

If you disclose or suggest that you have been abused, you are abusing a child, abusing a vulnerable adult or a child or vulnerable adult is in danger of abuse, I am required to report this information to social services and/or legal authorities. In the event there is admission to prenatal exposure to controlled substances that are potentially harmful, or children that are exposed to controlled substances or in the presence of domestic violence in the home, I am required to report to social services and/or legal authorities.

Informed Consent:

• You voluntarily agree to receive and participate in Bloom Upstate’s mentorship, therapy and family, tutor and peer group services and that you give consent for the organization to provide such services and when necessary make a referral to the appropriate facilities to address your needs.
• You understand and agree that you will participate in the planning and activities the organization provides and you can stop services at any time.
• You understand that no promises have been made to you as the results of the outcome of the program provided by the organization and you understand services provided in the program is a collaborative effort and that the results of your progress depends on your willingness to engage in the services provided.
• You understand that your information is confidential with the exception to the exemption to confidentiality listed in the confidentiality and privacy sections of this document
• You agree in the event of a crisis or an emergency to contact the numbers provide in the Telephone and emergency contact section.

By signing below you agree and understand these provision and give your consent to receive treatment services.