To be considered for assistance, you must read and agree to the following terms and conditions:

Limits of Confidentiality

The contents of a counseling, intake or assessment session are considered to be confidential. Both verbal information and written records about a client cannot be shared with another party without written consent of the client or the client’s legal guardian. The confidentiality of alcohol and drug abuse, patient records are protected by federal laws and regulations. (See 42 U.S.C. 290dd-3 and 42 U.S.D 290ee-3 for Federal laws and 42 CRF Part 2 for Federal regulations.) It is the policy of this program not to release any information about a client without an authorization to release information, except as follows:

Duty to Warn and Protect—When a client discloses intentions or a plan to harm another person, the intake person is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the intake person is required to notify legal authorities and make reasonable attempts to notify the family of the client, to prevent clear and immediate danger to a person or persons.

Abuse of Children and Vulnerable Adults—If a client states or suggest that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the intake person is required to report this information to the appropriate social service and or legal authorities, as mandated by law.

Authorization to Share Information

CharityTracker, is a shared, computerized record keeping system that captures information about people experiencing need for emergency services, including but not limited to assistance with utility bills, medications, rent/mortgage payments, etc. White County Caring & Sharing, Inc. (Administrating Agency) administers CharityTracker on behalf of participating agencies of the CharityTracker Assistance Network, including Helen First Baptist Church.

By typing my name and clicking the “Continue to Application” button below, I agree that I am requesting and authorizing Helen First Baptist Church of Helen, Georgia to obtain and use information for the purpose of determining eligibility for assistance from the following: employer or former employer, provider of any services that I am requesting assistance with, including landlord, mortgage lender, power or propane company, DFCS or White County School System, Family Connections or any other party that can provide information relating to my eligibility for assistance. I authorize Helen First Baptist Church to information collected about me or my dependents with other agencies who participate in CharityTracker.

This Release of Information will remain in effect unless I make a written request to Helen First Baptist Church that I no longer wish to participate in CharityTracker.

By typing my name and clicking the “Continue to Application” button below, I expressly grant permission for Helen First Baptist Church to discuss the information I provide in this application with other organizations to determine eligibility in obtaining assistance. (Please note, Helen First Baptist Church cannot process your application without this consent.)

I understand that typing my name and clicking the “Continue to Application” button below pledges that the information provided on this application is accurate & true.

I understand falsifying information constitutes fraud and no assistance will be given.