Gen PMTO Consent Form
Consent for the use of GenerationPMTO Recordings in training/education conducted byImplementation Sciences International, Inc.
GenerationPMTO Parent/Caregiver & Practitioner Consent
Purpose of the Consent form:
Implementation Sciences International, Inc. (ISII) is providing training and coaching for practitioners in GenerationPMTO, an evidence-based program designed to strengthen parenting and promote positive results for parents/caregivers and their children. The GenerationPMTO Model teaches parenting skills that encourage children’s cooperation and prosocial skills, prevent and reduce mild to severe behavior problems in youth ages 3-18, and promote healthy development. GenerationPMTO is delivered in individual family and group formats; Parenting Through Change (PTC) and Parenting Through Change for Reunification (PTC-R) are group formats of GenerationPMTO. The person(s) delivering the model, such as therapists, group leaders, coaches and trainers, is referred to in this form as the practitioner(s).
GenerationPMTO is an observational model; thus, we would like your permission to record these GenerationPMTO sessions. Recordings can include, but are not limited to, video, audio, cellphone, tablets, and conferencing software (e.g., Zoom) recordings. If you agree to participate, we will collect, store, and view recordings of sessions in which you will be participating for the purposes of coaching practitioners and monitoring fidelity:
ISII is providing training and coaching for practitioners in GenerationPMTO. Recording sessions is an essential part of GenerationPMTO and allows ISII coaches to give specific feedback to practitioners about their adherence to the core components of GenerationPMTO throughout the training process. Although the focus of the recording is the practitioner, clients (i.e., parents and child(ren)) will be in the recording as well as the practitioner to observe reactions in sessions.
Practitioners using the GenerationPMTO model are reviewed periodically to ensure they are practicing the model correctly. This is done by using a rating system called Fidelity of Implementation (FIMP). National and international FIMP Raters, who are also experienced GenerationPMTO practitioners, view and rate selected sessions.
Recordings used for evaluating practitioners’ work are stored on the “ISII Portal” while recordings used for the FIMP Raters are stored on “FIMP Central.”
Practitioners will be asked to upload recorded GenerationPMTO sessions, coaching sessions and training sessions to the ISII Portal in order for ISII coaches to review their work as practitioners. Then, recordings may be uploaded to the FIMP Central portal for use by the FIMP Raters, to test their work as raters. Often, recording segments uploaded to FIMP Central are brief, 10-15 minutes in length.
By signing this release, you give permission for your recording to be stored on the ISII Portal and on FIMP Central to be used for coaching, training, educational and evaluation purposes. The recordings may be used to train professionals in GenerationPMTO methods and procedures within and outside of ISII, nationally and internationally. The recordings may be used for the purposes of practitioner certification. Additionally, recordings may be shown at workshops, meetings, and other ISII-related professional activities.
Recordings of GenerationPMTO sessions will be stored for training and monitoring GenerationPMTO fidelity as well as to establish sets of recordings that will be used for educating, training, coaching, and maintaining GenerationPMTO effectiveness. These recordings will become the property of ISII. It will be the decision of the practitioner or the practitioner’s agency whether they keep a copy of the recording in their files after uploading it to the ISII Portal. Appropriate consent will be obtained from all parties in the recordings stored on the ISII Portal and FIMP Central. All children present in the recording will have their age tracked in the ISII Portal, and upon turning 18 years of age, if a consent is not signed by them, the recording will be destroyed.
It is possible that there may be no potential direct benefits to you from your participation in this model; however, there is potential that indirect or future benefits may result from your participation in this model. It is possible that the information gathered will be used to support the correct implementation of GenerationPMTO. Your participation may improve the quality of services for other children, youth and families wherever GenerationPMTO is practiced.
Potential risks, discomforts or inconvenience:
Potential risks, discomforts, or inconvenience involved in your participation in GenerationPMTO include possible violation of confidentiality and possible embarrassment in disclosing sensitive personal information.
To protect you from the potential risks, we have taken a number of steps, identified below.
Confidentiality of records:
To ensure confidentiality, the information stored in the ISII Portal and FIMP Central portals is secured following protocols outlined by HIPAA. The portals are only accessible to ISII staff/consultants and authorized GenerationPMTO FIMP Raters.
All recordings will be used respectfully and confidentially for education, training, coaching, supervision, and evaluation as outlined above.
The confidentiality of your records will be protected to the maximum extent permitted by law. As a participant in this model, you should be aware that there are exceptions to confidentiality. Exceptions include: if evidence of suspected abuse or threatened abuse is discovered, it must be reported to authorities.
During the course of your participation in GenerationPMTO, you may have questions about the recordings or the treatment procedures. Practitioners or agency leaders may be able to answer these questions, or you may speak with the ISII Administrator (541-485-2711) or email@example.com.
Voluntary Participation & Right to Withdraw these recordings:
Your participation is voluntary. You have the right to refuse to have your recording submitted. Your refusal to participate in recordings will involve no penalty or loss of benefits to which you are otherwise entitled. You have the right to withdraw from participation at any time, and also can require that the recordings that include you and your family be removed from the online portal(s).
By signing this consent form I am giving consent for the following:
A. Recordings of my sessions will be stored on the ISII Portal and may be stored on FIMP Central to be
used for coaching, training, educational and evaluation purposes.
B. Minimal demographic information about my family such as, parent name, parent date of birth or age,
child name, child date of birth or age, will be stored on the ISII Portal.
C. I understand that this is not a time-limited consent and will contact the ISII Administrator if I wish to
withdraw my information.
D. I have received written information about how to request that my recordings be destroyed.
Relationship to focus child:
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Gen PMTO Consent Form
Agree & Sign