Client Name _____________________________________________ Medicaid #____________________________ Birthdate _____________________________ Insurance # _____________________________________ TCM Intake Enrollment Packet Select and print the forms that...Client Intake and Consent Forms • September 3rd, 2019
Freedom of Choice I understand that the choice of providers is my responsibility and right as the client or guardian. I further understand that I have the right to contact the providers prior to selection so that I may determine the best provider. I also understand that I may at any time choose another provider for this service by notifying my current provider. Informed Consent I understand that participation in treatment does not guarantee anticipated outcomes. I understand that there may be unintended results of treatment affecting the client and other family/household members. I understand that providers are legally bound to report suspected abuse of the client or of other family members. I also understand that the providers have a duty to warn any intended victim of a threat to harm. Persons Participating in Home and Community Based Services I understand that I am giving permission to include in the client’s treatment sessions any persons present in the home, school or c
