Healthcare Living for Families

Healthcare Living For Families

9216 Liberty Road, Randallstown, MD 21133

www.healthcarelivingforfamilies.com

(P) 410-701-7384 ♦ 410-521-7005 (F)

COMPREHENSIVE CONSENT FORM

Regarding: ______Date of Birth: ______

SS # ______

I/We hereby authorize Healthcare Living for Families to obtain information from/send information to:

_OMHC______

______

______

Medical information, including immunization records

Inpatient and/or outpatient psychological/psychiatric/substance abuse treatment records

Academic and educational records, including achievement testing

____ Other communication as necessary ______

I authorize this clinic to speak by telephone with you about the reasons for referral, and relevant history, or diagnoses, and to share other information to assist with the client’s treatment and/or evaluation.

This authorization to release information is being made to aid in planning effective evaluation and treatment for this client. I understand that no services will be denied solely because I refuse to consent to this release of information, and that I am not obligated to release them. I do release them because I believe they are necessary to assist in the development of the best possible treatment plan for the client.

In consideration of this consent, I hereby release the above source of records from any and all liability arising there from. I understand that I may void this authorization, except for action already taken, at any time by means of a written letter revoking the authorization and transfer of information, but that this revocation is not retroactive. Unless expressly revoked earlier, this consent expires upon completion of the current treatment and/or one year from current date.

Signature of Client______Date______

Signature of Parent/Guardian______Date______

Signature of Witness______Date______

Healthcare Living For Families

9216 Liberty Road, Randallstown, MD 21133

www.healthcarelivingforfamilies.com

(P) 410-701-7384 ♦ 410-521-7005 (F)

COMPREHENSIVE CONSENT FORM

Regarding: ______Date of Birth: ______

SS # ______

I/We hereby authorize Healthcare Living for Families to obtain information from/send information to:

PCP______

______

______

Medical information, including immunization records

Inpatient and/or outpatient psychological/psychiatric/substance abuse treatment records

Academic and educational records, including achievement testing

____ Other communication as necessary ______

I authorize this clinic to speak by telephone with you about the reasons for referral, and relevant history, or diagnoses, and to share other information to assist with the client’s treatment and/or evaluation.

This authorization to release information is being made to aid in planning effective evaluation and treatment for this client. I understand that no services will be denied solely because I refuse to consent to this release of information, and that I am not obligated to release them. I do release them because I believe they are necessary to assist in the development of the best possible treatment plan for the client.

In consideration of this consent, I hereby release the above source of records from any and all liability arising there from. I understand that I may void this authorization, except for action already taken, at any time by means of a written letter revoking the authorization and transfer of information, but that this revocation is not retroactive. Unless expressly revoked earlier, this consent expires upon completion of the current treatment and/or one year from current date.

Signature of Client______Date______

Signature of Parent/Guardian______Date______

Signature of Witness______Date______

Healthcare Living For Families

9216 Liberty Road, Randallstown, MD 21133

www.healthcarelivingforfamilies.com

(P) 410-701-7384 ♦ 410-521-7005 (F)

COMPREHENSIVE CONSENT FORM

Regarding: ______Date of Birth: ______

SS # ______

I/We hereby authorize Healthcare Living for Families to obtain information from/send information to:

______

______

______

Medical information, including immunization records

Inpatient and/or outpatient psychological/psychiatric/substance abuse treatment records

Academic and educational records, including achievement testing

____ Other communication as necessary ______

I authorize this clinic to speak by telephone with you about the reasons for referral, and relevant history, or diagnoses, and to share other information to assist with the client’s treatment and/or evaluation.

This authorization to release information is being made to aid in planning effective evaluation and treatment for this client. I understand that no services will be denied solely because I refuse to consent to this release of information, and that I am not obligated to release them. I do release them because I believe they are necessary to assist in the development of the best possible treatment plan for the client.

In consideration of this consent, I hereby release the above source of records from any and all liability arising there from. I understand that I may void this authorization, except for action already taken, at any time by means of a written letter revoking the authorization and transfer of information, but that this revocation is not retroactive. Unless expressly revoked earlier, this consent expires upon completion of the current treatment and/or one year from current date.

Signature of Client______Date______

Signature of Parent/Guardian______Date______

Signature of Witness______Date______

Discharge and Transition Plan

*  Healthcare Living for Families is dedicated to quality care and service. It is important that you understand our policy for transitioning to a lower level of service when goals are met and/or treatment is no longer necessary.

*  You may be discharged from services if you have not participated in treatment for a period of 30 days or you have missed three consecutive appointments. A discharge warning letter will be mailed to your home prior to termination from the program.

*  A decision to terminate may be made by your treatment team if all of your identified treatment goals have been met and symptoms have stabilized.

*  If you are unable to attend treatment services for a temporary period of time due to hospitalization, traveling or other temporary reason your services will remain open as long as information is communicated with your direct service provider.

*  Program Services may be discontinued at the request of the consumer or their legal guardian.

*  Discharge and transition will be a collaborative effort between all members of your treatment team. A set transition plan will be set in order to facilitate transfer to new level of care.

*  Initial treatment goal: establish rapport with direct service staff and participate in assessment and development of individual rehabilitation goals and objectives. Services will be provided both in the home, community and in the office. Client formal Individual Rehabilitation Plan (IRP) will be developed within 30 days of start of services.

______

Signature of Client or Client representative Date

______

Rehabilitation Specialist Date