Client Intake Application & Consent

Parent/Guardian Service Request

Parent/Guardian Full Name

Relationship to Client

Phone Number

Email Address

Preferred Method of Contact

Best Time to Contact

Reason for Requesting Service and Concern

Choose state
Choose StateFloridaTexas

Client Information

Today's Date

Last name

First name

Middle Initials

S.S.N (Last four recommended)

Date of Birth

Martial Status

Race

Sex

Mailing Address (Street)

Mailing Address (City, State, Zip)

Email Address

Home Phone

Work Phone

Occupation

Primary Language

Emergency Contact (not residing with you)

Emergency Phone

Responsible Party Information

First & Last Name

Relationship

Daytime Phone

Home Phone

Mailing Address(Street)

Mailing Address(City,State,Zip)

Employer

S.S.N (Last 4)

DOB

Insurance Information

Insurance Provider
MedicaidAetna Better HealthBCBSCommunity Health ChoiceCommunity FirstDellMolinaSuperiorSunshine HealthTexas ChildrenUHCWellpoint

Insured’s Name on Card

Policy Number

Group Number

Insured's S.S.N (last 4)

Insured's Date of Birth

Consent For Treatment

Client Name

Client D.O.B.

Consent For Service, Emergency, & Transportation

I apply for and consent to such medical, psychiatric and/or other services as the agency may indicate, including diagnostic tests and counseling. I agree to cooperate in the implementation of the services. I understand the agency may have to disclose information in emergency situations to assist with a crisis or emergency incident. I also agree the agency will not be held to any litigation if I accept transportation from an agency worker.

Family Involvement Consent / Denial (Initial One Option)

Initials

Do you give consent to have the family members you list be involved in
planning and delivery of services.?
yesno

Family Member Name

Relationship

Phone

Family Member Name

Relationship

Phone

Follow-up Contact Consent (Initial One Option)

Initials

Do you consent to follow up contacts?
yesno

Contact Person 1 - Name

Contact Person 1 - Phone

Contact Person 1 - Address

Contact Person 2 - Name

Contact Person 2 - Phone

Contact Person 2 - Address

Signature



Clear

Medication Document

+ Add

Parent Consent Form (School-Based)

Purpose is for AOC Outreach Services representative to conduct school sessions with the participant listed below. Any questions regarding this request please
contact the parent/guardian.

To (School Name)

Student's Name

Action Requested (Initial One Option)

We are requesting your consent for the action selected below. The attached written notice explains the action to be taken.

• Initial Evaluation of your child

• Reevaluation of your child (using additional assessments)

• Other (specify):

Initials

Do you give your consent?
yesno

Agency Representative

Parent/Guardian Name

Signature


Clear

Authorization For Release Of Records (Release Of Information)

I hereby authorize the holder of records to release to Peter Project Outreach any and all medical, confidential, employment, educational, or other information requested regarding the above-named individual that is necessary for treatment, coordination of care, and/or payment activities.

The disclosure may include, but is not limited to:

• Immunization records

• Psychological evaluations

• School records and educational information (including IEP/504 plans)

• Annual physical information

• Aftercare or discharge planning information

• Medication information

• Legal or custody agreements

• Other relevant information necessary for coordination of care

I understand this authorization is voluntary and may be revoked in writing at any time, except to the extent that action has been taken in reliance upon it. I understand that information re-disclosed by a recipient that is not a health plan or health care provider may no longer be protected by federal privacy
regulations.

This release will expire one (1) year from the date of signature unless otherwise noted.

Signature


Clear

relationship to minor (if applicable)

How Can We Help You?

Guardians, we want to help you. What can we do to help you in the mission of delivering our services?

Please list things we can do that will help you in your day-to-day.

Peter Project Outreach – Acknowledgement Form

I acknowledge that I have received or been given access to Peter Project Outreach Inc.’s Client Rights information, Client Handbook, and all required forms related to treatment and services provided by the agency.

I give consent for myself and/or my child to receive services through Peter Project Outreach Inc. I authorize the agency to use and release information as needed to coordinate services, verify insurance, request authorizations, process claims, and complete other service-related or administrative requirements.
I understand that I have the right to choose my service provider. If I decide not to continue services with Peter Project Outreach Inc., I may request assistance with transferring services to another provider. I also understand that I have the right to refuse or discontinue services at any time, and that refusing services does not prevent me from receiving other services for which I may qualify.
I understand that insurance coverage is not guaranteed and that I may be responsible for charges not covered or paid by insurance, unless prohibited by law or payer requirements.
I confirm that the information I have provided is true and accurate to the best of my knowledge. I also agree to follow the applicable policies, expectations, and procedures outlined in Peter Project Outreach Inc.’s Client Handbook.

Signature


Clear

Faith Disclosure, Consent & Disclaimer Notice

Organizational Disclosure

Peter Project 21:17 is a faith-based initiative program whose sole purpose is to connect Peter Project Outreach and local faith-based organizations to help support families and children in the community with access to behavioral and mental health services.

Faith-based organizations may serve as referral sources or community support partners. However, all behavioral and mental health services provided through Peter Project 21:17 are delivered exclusively by qualified professionals in accordance with Texas Medicaid guidelines and professional standards of care.

Religious instruction, spiritual counselling, or faith-based activities are not part of Medicaid-covered treatment services. Participation in any faith-related community activity is voluntary and separate from clinical services.

The clinical services provided are evidence-based, medically necessary, and guided by the individualised treatment plan, regardless of a client’s religious affiliation, beliefs, or non-belief.

Voluntary Participation

Participation in any faith-informed or values-based discussion is voluntary. Clients may decline or withdraw consent at any time without impact to services.

Client Rights

• Right to request a non-faith-aligned provider

• Right to decline faith-related discussion

• Right to withdraw consent at any time

• Right to receive services without discrimination

Prohibited Activities

Medicaid funds are not used for worship, prayer as treatment, religious instruction, or proselytizing.

Acknowledgement & Consent

I acknowledge receipt of this disclosure, understand my rights, and consent to receive clinical, evidence-based services under these conditions.

Client/Guardian Name Signature Clear

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