FIMR Maternal Interview Consent Form

FIMR Maternal Interview Consent Form

Purpose of the Program: The Inter-Tribal Council of Michigan Healthy Start Team has a program called the Bamidyang Initiative, which supports people who have experienced perinatal, infant, or reproductive loss. The program administers professional, caring support to grieving families in the form of home or office visits, with phone consultations as needed.

INTERVIEW: We would like to give you the opportunity to share your story about the birth and death of your child so we can help other families who experience similar tragedies.

Your Story: The experience of talking about the death of a child is different for everyone. For some people, talking about their baby is extremely difficult. For others, sharing the story of their child’s life and death brings comfort and hope to the family. In either case, whatever you feel comfortable sharing will have great value to your healing journey. If you agree, we may share parts of your story with our Team so that we can help other families who experience similar tragedies. The Staff Member may ask to record your story so they can focus on your needs. If you agree, the tape will be listened to after the visit then destroyed to protect your identity once we have documented the important things you shared with us.

Confidentiality: All information that identifies you, your family, your location, or your health care providers will be kept private. All our team members have signed a confidentiality agreement outlining how they will maintain your privacy. As required by law, we must report any child abuse, neglect, or harm to others or self. Therefore, confidentiality will be protected to the full extent permitted by law.

Choice: Whether you choose to participate in the program is completely up to you. You may choose to answer any or all questions. You may skip questions. There is no minimum amount of questions to be answered in order to receive a gift card. All your responses are valuable and appreciated.

Questions: If you have any questions, concerns, or requests, please let the Staff Member know. We want to assure your full comfort with this process.

CONSENT: I have read this form and understand the purpose of the FIMR Maternal Interview. I agree to hold harmless the Staff Members and agencies who provide support in this program. I understand that if I’m feeling thoughts of self-harm or suicide, I will immediately call 911, local Emergency Department or Suicide Hotline. I understand that all information obtained through my participation in the program will be kept strictly confidential to the fullest extent of the law.

Gift Card: You may receive a one-time payment of $30.00 [STORE] gift card to thank you for your time and participation in this program. You will receive payment for any level of participation; there is no minimum requirement for participation.

☐Gift Card Received ______Staff Member Initials

I hereby give my consent to participate in the FIMR Maternal Interview.

Family Member Name PRINTED:______

Family Member SIGNATURE:______

Date:______

Staff Member Name PRINTED:______

Staff Member SIGNATURE:______

Date:______

Bamidyang Initiative // Tribe Name // Tribe Address // Phone Number // Fax Number