together in texas
For Couples For Providers
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Search for Marriage Education Services
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Registration for Twogether Service Provider


1. Name of person completing this form.
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2. Who would we contact to update the information on this organization in the future.

 
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* Required Field
This field will appear on the business card.

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Your Organization Type in this box only.
This field will appear on the business card.

4. ADDRESS

What is the street address of your organization (main office)?

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Is this address confidential?  
Is this address a residence?  

What is the mailing address of your organization (main office)?

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Is this address confidential?  

This field will appear on the business card.
 

5. ORGANIZATION FUNDING

What are the sources of funding for the organization? Please choose all that apply.











6. Service Goals



 

TYPE OF SERVICE*

1. What type of marriage education do you provide?









2. How many hours is your program?*



**Other

3. What Type of schedule do you provide for your program?






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This field will appear on the business card.

 

NAME OF CURRICULUM*



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1. LOCATION SERVED

If you would like to expand the area that your classes are recognized in, please list the city & zip code(s) of the surrounding area. Your primary city & zip code is required.

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2. If you have one specific location where all services are offered, please complete this section.

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Address :
County :
 

Is this site accessible by public transportation (within 1/4 mile of a stop)?

    

Is this site accessible by wheelchair?

    

3. DAYS and HOURS of OPERATION

On what days and during what hours do you intend to offer services? (Check all that apply)






 

1. TARGET POPULATION






Do you offer services in Spanish?

     


Do you offer services in any other language(not English or Spanish)?

     


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2. FEES

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Type Note
  
  


 

Complete ONLY if a program and you offer on-going registration

1. Person to contact to register:

 

Premarital Education Program Curriculum Certification
&
Security And Privacy Agreement (SPA)

Please read the following user certification. You must accept the terms of this certification before continuing as a Twogether in Texas service provider.

Name of the Organization :
Name of the Curriculum :

This curriculum meets or exceeds the criteria in compliance with Section 2.013, Texas Family Code. Specifically, the curriculum offered will be a minimum of eight hours and include instruction in:
(1) Conflict management;
(2) Communication skills; and
(3) The key components of a successful marriage

In addition, the curriculum offered meets or exceeds the requirements as stipulated
by statute provides the skills-based and research-based curricula of:

(1) The United States Department of Health and Human Services healthy marriage initiative;
(2) The National Healthy Marriage Resource Center;
(3) Criteria developed by the Health and Human Services Commission; or
(4) Other similar resources.


The services offered will be conducted by instructors trained in this skills-based and research-based marriage preparation curriculum.
HHSC determines if the curriculum proposed by the provider meets the statutory requirements. HHSC has no authority over the marriage license discount. Similarly, HHSC has no authority to take adverse action against any provider who refuses to educate individuals based on the provider's religious belief.
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Health and Human Services

SECURITY AND PRIVACY AGREEMENT (SPA)

The purpose of this agreement is to help you understand your duties regarding confidential information.

You will be required to reaffirm your understanding of these duties on a periodic basis. As a volunteer using HHS Systems with access to what this agreement refers to as "confidential information", it is important that you understand the requirements for protecting this information. Confidential information is valuable, sensitive and is protected by law as well as HHS policies. Confidential information includes the following:

  • Any information by which the identity of a client can be determined, either directly or indirectly
  • Employees, contractors, volunteers, personal information such as home addresses, home phone numbers, social security numbers, etc.
  • Patient/client such as records, conversations, admittance information, diagnosis, prognosis, treatment plan, financial information, etc.
  • HHS information such as financial information, internal reports, memos, contracts, peer review information, communications, proprietary computer software, etc.
  • Third party information such as vendor information, etc.
  • Any information (patient or otherwise) that is classified confidential by federal or state law and Health and Human Service (HHS) standards.
  • You acknowledge you are not a Business Associate of HHSC for HIPAA related issues and acknowledge that you acting on behalf your clients and not on behalf of HHSC.

The intent of these laws and policies is to assure that confidential information will remain protected and used only as necessary to accomplish your organization's mission. As a user of HHS systems you may have access to some or all of this confidential information through a computer system or through your associated activities with HHS Systems. You are required to conduct yourself in conformance to applicable laws and HHS policies governing confidential information. Your principle obligations in this area are outlined below. The violation of any of these duties will subject you to actions which might include, but is not limited to, termination of access privileges, and/or legal liability.

Accordingly, as a condition of and in consideration of your access to confidential information, you agree that:

1. You will use confidential information only as needed to perform legitimate duties. This means, among other things, that:

  • You will only access confidential information for which you have a need to know; and
  • You will not in any way divulge, copy, release, sell, loan, review, alter, or destroy any confidential information except as properly authorized within the scope of your activities; and
  • You will not misuse confidential information or carelessly handle confidential information.

2. You will safeguard and will not disclose your password or any other authorization you have that allows you to access confidential information, except as permitted by law.

3. You acknowledge that you will receive and will be required to use a personal security identification code (User ID and Password) to gain access to and to use HHS Systems. Further you agree that the security identification code provided will only be used by you, and that you accept responsibility for all activities undertaken making use of your User ID/password and other authorization. If you suspect your personal security code has been compromised, you shall:

  • Change your personal security identification code immediately
  • Notify your supervisor
  • Notify HHS' Chief Information Security Office through the HHS Privacy Office

4. You will report activities by any other individual or entity that you suspect may compromise the confidentiality, integrity or availability of confidential information. Reports are made in good faith about suspect activities and will be held in confidence to the extent permitted by law, including the name of the individual reporting the activities.

5. You understand that your obligations regarding HHS information under this Agreement will continue after termination of your association with HHS or HHS applications.

6. You understand that your privileges hereunder are subject to periodic review, revision, and if appropriate, renewal.

7. You understand that you have no right or ownership interest in any confidential information referred to in this Agreement. HHS may revoke your access code or other authorized access to confidential information.

8. You will, at all times, safeguard and retain the confidentiality, integrity and availability of confidential information.

9. You understand that your failure to comply with this Agreement may also result in the loss of access privileges to HHS applications.

By completing this form and signing below, you are providing the requested information to HHS in order to gain access to secured systems. This information will not be shared in any manner or for any reason not permitted by the laws of the State of Texas. You may, in writing, request copies of this information at any time and may request that any information in error be corrected.
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I hereby certify that the above information is a true and correct description of the Twogether in Texas Healthy Marriage services that will be offered by as a Twogether in Texas provider.

Name :  
Title :  
Telephone number :  
e-mail :  




Authorization to Publish Information

Please read carefully

Organization Name : 

In addition to relaying information about your organization’s services over the telephone, 2-1-1 Texas and Twogether in Texas will disseminate information in printed directories and in an online database, which is available at www.211texas.org. Many social service professionals and volunteers at churches, nonprofit organizations, schools, and government agencies use this information to refer their clients to organizations and programs. Please feel free to call us if you have concerns related to this form.

This signed release form will be retained on file as an ongoing authorization that 2-1-1 Texas and Twogether in Texas may provide information to the public regarding the services of the above-named agency.

, I hereby authorize Twogether in Texas and 2-1-1 Texas Information and Referral Network to utilize my organization’s information for inclusion in any print or online publications of community resources. Information that is noted as confidential on the agency/program forms will not be given to callers, nor will it be published in other formats.

, I do not offer classes for the general public so Twogether in Texas and the 2-1-1 Texas Information and Referral Network do not have authorization to print my organization’s information in any print or online publication of community resources. The information will continue to be provided to individuals who call the 2-1-1 helpline for assistance.


Verification :

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Name :  

Title :  

Date    8/16/2017