Client Intake & Eligibility Form

Information

SECTION ONE: CLIENT

You have received the full and legal name of the client.
You have received the accurate and legal birthdate of the client.
You have received the accurate and official social security number for the client (e.g. Review the actual social security card).
You have received the insurance provider's name and number (e.g. Medicaid Billing Number).
You have verified the client's age (e.g. If a minor or in the care of an authorized representative complete section two).
You have documented the client's address.
You have documented the client's telephone number (e.g. Ask the client for the number best to contact him/her).
The client is eligible for services.
You have listed the name of the staff person that facilitated the eligibility determination.

You have documented the name and relationship of the PGA.
You have documented the date of birth for the PGA.
You have documented the contact information of the PGA (e.g. Include address and telephone number).

You have communicated to the client and have ensured he/she understands his/her rights and responsibilities (Note: ensure you provide the client with full proof of their rights and responsibilities) 1. Right to select a service provider of choice. 2. Right to receive medically necessary service according to your level of intensity and as determined by a (QMHP). 3. You have the right to discontinue services at any time and should give requisite notice of your decision. 4. You and/or your PGA have the right to be actively involved in development and provision of services provided within our program. 5. You have the right to have your confidentiality maintained at all times and no information will be shared without your written authorization. 6. You have the right and will be provided services in a safe and efficient manner. 7. You have the right and will be required to sign and receive a copy of your Rehabilitation Treatment Plan. 8. You have the right and will have developed goals and objectives that are time specific, measurable, observable, achievable, realistic, time limited, outcome driven, individualized, progressive, and developmentally and age appropriate.
You have communicated to the client and or his PGA their responsibilities to the program. A. Participate in the development and implementation of their individualized Rehabilitation Treatment Plan. B. Keep all scheduled appointments. C. Inform our program of any changes of coverage or eligibility.

You have communicated to the client our confidentiality policies in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and violations from either party could result in dis-enrollment from programming as a client and disqualification as a service provider.

You have communicated all available service options to the client. ~Basic Skills Training (BST) ~Program for Assertive Community Treatment (PACT) ~Day Treatment ~Peer to Peer ~Psychosocial Rehabilitation (PSR) ~Crisis Intervention

I acknowledge that I have read, understand and accept the information that has been shared with me the (Client) and/or the PGA during this intake and eligibility process.
This form was completed on what date and at what time
Client signature
If applicable, PGA signature
Staff signature