The Human Development Center, Inc.

“…ever increasing opportunities for many”

General 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#:

6833 W. Fond Du Lac Ave Milwaukee, WI 53216P.O. Box 274 Milwaukee, WI 53201

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

Fax: (414) 449-9912Website:

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

I understand that from time to time my assigned Service Provider may have another Human

Development Center Employee with them for training or Quality Assurance purposes.

Parent/GuardianDateParent/Guardian Printed Name

Witness SignatureDateWitness Printed Name

Client SignatureDateClient Printed Name

6833 W. Fond Du Lac Ave Milwaukee, WI 53218P.O. Box 274 Milwaukee, WI 53201

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

Fax: (414) 449-9912Website:

  1. Confidentiality & Anonymity
  1. 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.
  1. Duty to Warn
  1. 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.
  1. Voluntary Participation
  1. 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

6833 W. Fond Du Lac Ave Milwaukee, WI 53218P.O. Box 274 Milwaukee, WI 53201

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

Fax: (414) 449-9912Website:

Transportation Consent Form

Youth’s Name DOB

Print

Of

(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.

6833 W. Fond Du Lac Ave Milwaukee, WI 53218P.O. Box 274 Milwaukee, WI 53201

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

Fax: (414) 449-9912Website:

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

ecords sent: ______Date: ______

6833 W. Fond Du Lac Ave Milwaukee, WI 53218P.O. Box 274 Milwaukee, WI 53201

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

Fax: (414) 449-9912Website:

Please note the items below:

  1. Client and/or family will be informed of other options for treatment of mental health disorders and also provide them with alternative agency’s offering services if there is a mismatch between client and referred provider.
  2. Client and/or family will be informed of changes that may present as a result of achieving the goals of the treatment plan. This may also be followed by a recommended continuance of treatment or referral for other existing services in the community.
  3. Client and/or family will be informed of the potential positive benefits of the treatment recommendations in the referral packet and from the client-centered treatment plan developed early on in the treatment process.
  4. Client and/or family will be informed of the estimated time that treatment services will take and the potential benefits of achieving the goals listed on the treatment plan. The treatment plan will be reviewed and/or revised every 90 days.
  5. Client and/or family will be informed of their rights and responsibility in creating a client-centered treatment plan. This will include the right to stop services at any time, change provider at any time, and to modify the treatment plan at any time.
  6. Client and/or family will be informed of the type of services that will be provided to achieve the goals listed in the client-centered treatment plan.
  7. Client and/or family will be informed that they will not be responsible for any fees for services as a result of participating in Wraparound Milwaukee’s Medicaid program.
  8. Client and/or family will be informed of the agency’s grievance procedure and appropriate staff to communicate with if there is a grievance under DHS 94.
  9. Client and/or family will be informed of the agency emergency on call contact person and the appropriate telephone number. This will also include the contact information for Milwaukee County’s Mobile Urgent Treatment Team (MUTT).
  10. Client and/or family will be informed that the potential exists to be involuntarily discharged as a result of symptoms of their mental health disability. Referrals will be provided for client’s that may need a level of care not provided by this agency.

______Guardian Signature Date

______Witness Signature Date