TRANSPORTATION AUTHORIZATION

Emergency Contact Information

Same as above

Client Name*

First Last

Date*

Same as above

Parent/Guardian Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Cell Phone*

Work

Home Phone

In case of an emergency and the parent(s)/guardian(s) cannot be reached, please contact one of the following persons:

Emergency Contact 1*

First

Relationship

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Emergency Contact 2*

First

Relationship

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Authorization for Transportation Services*

I authorize The Potter’s House Family and Children Treatment Center to transport my child to and from locations that will assist in obtaining educational, dental, medical, psychological, or other services required as a part of CORE Services.

Please give specific instructions if your child needs special assistance, equipment, or materials when transported

List any chronic medical condition or allergies your child may have as well as any medications your child may take

Authorization for Emergency Medical Care

In case of an accident or illness requiring medical attention, the undersigned authorize The Potter’s House Family and Children Treatment Center to call a health provider or take my child to the nearest hospital or doctor, and it is understood that if possible, their services will be obtained. If neither parents nor preferred care provider can be contacted, The Potter’s House Family and Children Treatment Center is authorized to contact another health care provider. It is also understood that this agreement covers only those situations, which in the best judgment of The Potter’s House Family and Children Treatment Center are true emergencies.

Same as above

Healthcare Provider Name

First

Healthcare Provider Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone

Do you have a preferred hospital?*

Yes
No

Preferred Hospital Name

First

Preferred Hospital Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Emergency Care Authorization*

I authorize emergency treatment deemed necessary by a physician in the event that I cannot be reached for permission. I agree to be responsible for the cost of such emergency medical care.

Name of person completing the form

First Last

Signature of person completing the form*

Relationship to client*

Self
Parent/Legal Guardian

Step 1 of 16

INTAKE SCREENING SUMMARY - GENERAL INFORMATION

EMPLOYMENT/EDUCATION

LEGAL STATUS

FINANCIAL INFORMATION

FAMILY MENTAL HEALTH HISTORY

Have client's family members been diagnosed with any of the following? Check all that apply

HEALTH AND MENTAL HEALTH INFORMATION

Health History

Mental Health History

Abuse History

Substance Use

SIGNATURE

CONSENT FOR TREATMENT AGREEMENT

RIGHT TO REFUSE TREATMENT

RIGHT TO WITHDRAW CONSENT FOR TREATMENT

SIGNATURE

RECEIPT AND ACKNOWLEDGEMENT OF HIPAA NOTICE OF PRIVACY PRACTICES

SIGNATURE

RECEIPT AND ACKNOWLEDGEMENT OF POLICIES AND RIGHTS

SIGNATURE

TRANSPORTATION AUTHORIZATION

Emergency Contact Information

Authorization for Emergency Medical Care

ACKNOWLEDGMENT OF SERVICE REQUIREMENTS

ACKNOWLEDGMENT OF SERVICE REQUIREMENTS

SIGNATURE

ACKNOWLEDGMENT OF NO-SHOW POLICY

SIGNATURE

HANDBOOK FOR PERSONS RECEIVING SERVICES

SIGNATURE