The Human Development Center, Inc

The Human Development Center, Inc.

“…ever increasing opportunities for many”

Mentoring Consent Packet

Date:Medicaid#:

Case Name:SS#

Client Name:SS#

Race/Ethnicity:

Address:

Parent/Guardian:Phone:

Address:

Emergency Contact:Phone:

Insurance Company:Policy#

(If applicable)

Case Manager:Agency:

Case Manager Phone:Case Manager Fax:

Svc: Code: Hrs/month

Svc: Code: Hrs/month:

Assigned Worker(s):

Health Concerns:

Presenting Problem/Issues to be addressed:

Special Requests:

Initial meeting date/time:

T19 Confirmation#:

Service Consent Form

I , attest that I am the parent/guardian for

Parent/Guardian

, and by signing this form I am giving informed

consent for services for the above named client to be provided by the Human Development

Center, Inc. for a period of one year beginning on .

Today’s Date

Parent/GuardianDateParent/Guardian Printed Name

Witness SignatureDateWitness Printed Name

Client SignatureDateClient Printed Name

CLIENT RIGHTS FORM

Confidentiality & Anonymity

As a client of the Human Development Center, Inc. all of your case information will be held confidential and anonymous. If your case information is used for research or evaluation purposes your name will not be linked to any information analyzed.

Duty to Warn

Any information you disclose while services are being provided to you will not be released unless you express a clear unquestionable intent to harm a named individual or yourself. In which case, precautions will be taken (such as: Informing others, police, care coordinator(s), parents, etc.) to prevent the named victim and yourself from being harmed.

Voicemail and Text Message Consent

As a client of Human Development Center, Inc., I give permission to receive voicemail and text messages on the cellular numbers I provide to the crisis worker.

Voluntary Participation

Your participation in services provided by representatives of the Human Development Center, Inc. is entirely voluntary. You may revoke your involvement in any service at any time or you may exercise the right to request another worker, if you feel the need to do so.

I have thoroughly read and clearly understand my rights as a client of the Human Development Center, Inc. By signing below, I attest to reading and understanding my rights as given on this document.

Client SignatureDateClient Printed Name

Parent/Guardian SignatureDateParent/Guardian Printed Name

Witness SignatureDateWitness Printed Name

Transportation Consent Form

Youth’s Name DOB

(Name of Provider)(Name of Agency)

Has permission to pick up and transport my child fromthrough the Termination of services from this Agency.

Special Considerations / Medical-Medication Issues/ Limitations:

Signature of Legal GuardianRelationship to YouthDate

Signature of YouthDate

WITNESSED BY:

Print Name of Witness

Signature of WitnessDate Witnessed

Agency AddressAgency Phone

Emergency Contact:

Name:Phone:

Address:

City: State: Zip Code:

Unless otherwise specified, this consent will expire 12 months from the date it was signed. This consent or any part of this consent may be canceled at any time with written notification.

Name: ______

LastFirst

Address: ______

______

DOB: ______

CONSENT FOR DISCLOSURE OF CONFIDENTIAL INFORMATION

INFORMATION TO BE RELEASED BY: ______

INFORMANT ADDRESS: ______

______

PHONE: ______EMAIL: ______

The purpose of this document is to convey my signed consent so that the above named individual/agency may disclose information to the individual/agency listed below as recipient

Purpose(s) or need(s) for the disclosed information: ______

______

Disclosure of the following specific information concerning the above named client/student is authorized to the individual/agency listed as recipient:

_____All psychiatric reports which may be available

_____All psychological reports which may be available

_____All pertinent medical information

_____All social work reports

_____All education testing reports

_____All School records which may be available

_____Drug records

_____I also give my permission for mutual discussion (either in person, by mail, or by phone)

by informant and the individual/agency listed below (Recipient), regarding your findings, professional opinions and suggestion for intervention.

_____Other ______

______

INFORMATION RELEASED TO: ______

(Recipient)

Address: ______

Phone: ______Email: ______

I understand the Human Development Center operates under current provisions/requirements of Federal Family Rights and Privacy Act and Wisconsin Statutes. You are hereby released from any liability on account of disclosure of any information provided as a result of this consent.

This release is valid for one year from the date of my signature

______

Legal Guardian Signature Relationship to YouthDate

______

Print Legal Guardian SignatureWitness SignaturePrint Witness Signature

Records sent: ______Date: ______

4011 W Capitol Dr. Ste. 200 Milwaukee, WI 53216P.O. Box 274 Milwaukee, WI 53201

Phone: (414) 449-9908Toll Free: (866) 567-8722

Fax: (414) 449-9912Website:

WRAPAROUND MILWAUKEE

CONSENT/ACKNOWLEDGEMENT FORM

The following items are essential to the care of your family while participating in the Wraparound Milwaukee program. Please review each area and indicate which areas you approve by initialing the appropriate line after each heading.

Initial to Approve

1. ACKNOWLEDGEMENT OF RECEIPT OF CLIENTS RIGHTS COMPLAINT/GRIEVANCE PROCEDURE

I have read and understand my legal client rights as a participant of the Wraparound Milwaukee program and recipient of services provided through the Wraparound Integrated Provider Network. By signing below I acknowledge that I have received a copy of the "Client Rights and Grievance Procedure brochure." ______

2.ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY STATEMENT______

I have received, read and understand the Privacy Statement of Wraparound Milwaukee, and understand the program's commitment to protecting any identifiable client information as mandated by law.

3.CONSENT FOR TRANSPORTATION______

I hereby give my consent for my child/children to be transported by Wraparound Milwaukee and its agents as needed.

Unless otherwise specified below, this consent will expire 12 months from the date it was signed. This consent or any part of this consent may be canceled at any time with written notification as outlined on the back of this form.

Youth/Enrollee Name (please print)

DOB (Date, event or condition upon which consent will expire):

Parent /Legal Guardian's Signature:

Date:

Youth/Enrollees Signature (age 14 and older should sign):

Date:

Witness Signature: Date:

______

YOUR RIGHTS WITH RESPECT TO THIS CONSENT:

Right to Refuse to Sign This Consent/Acknowledgement Form -1 understand that I am under no obligation to sign this form

and that Wraparound Milwaukee may not condition treatment, payment, or enrollment on my decision to sign this authorization.

Right to Withdraw This Consent - I understand that I have the right to withdraw consent for any of the items identified on the previous page at any time by providing a written statement of withdrawal to Pamela Erdman, Wraparound Quality Assurance. (The statement must identify what Consent that is being withdrawn, be dated and signed). I am aware that my withdrawal will not be effective until received by Wraparound Milwaukee.

AUTHORIZATION FOR RELEASEOF HEALTH INFORMATION

(May be used following completion of Enrollment Packet Authorization Form)

PURPOSE OF DISCLOSURE: Release of Mental Health, AODA (Alcohol and Other Drug Addiction) and physical health information that will be used to plan and provide for the care, treatment and services for:

(Youth Name)(Date of Birth)

I authorize Wraparound Milwaukee, its contracted Care Coordination Agencies, and/or the Mobile Urgent Treatment Team to release/exchange health related information including diagnosis, prognosis, treatment and planning related to the above named youth's enrollment in Wraparound Milwaukee to the appropriate staff at the following agency/s:

AGENCY NAME / INDIVIDUAL NAME

SHARED DOCUMENTS/INFORMATION

(Check those that apply.)

Demographic Plan of ReferralOther*

Information Only Care for Services (Specify Below)