Application for Case Management

Thank you for your interest in working with Project Oz. Your application is being reviewed, and a staff member will contact you within the next seven business days. In the meantime, you are invited to attend one of the following Life Skills classes:

• Pregnant/parenting female applicants – class is located at the YWCA (1201 N. Hershey Rd.,
  Bloomington) every Monday from 5:00-6:00pm; childcare and a meal are provided.
• All applicants– class is located at Project OZ (1105 W. Front St., Bloomington) every Tuesday from 5:00-6:00pm; a meal is provided.

If you do not have a cell phone for staff to contact you after submitting your application, arrive to class 15 minutes prior to its start time to meet with a caseworker; no appointment is necessary.

As we review your application, consider the following resources:

• Do you have friends or family members whom you can stay with temporarily?
• Have you looked into staying at one of the two local shelters in Bloomington? (Home Sweet Home
  Ministries303 E. Oakland Ave. 309-828-7356, Safe Harbor 611 W. Washington St. 309-829-9476)
• Have you filled out an application for subsidized housing through the Bloomington Housing Authority?
  (309-829-3360)
• Have you filled out an application for rental assistance through Bloomington or Normal Township
  offices? (Bloomington: 309-828-2356, Normal: 309-452-2060)

In addition to these above options, Project Oz may be able to help with a variety of needs including transportation, personal hygiene supplies, aconfidential person to talk with, and other referral services as needed.

Please call the office (309-827-0377) with any questions, concerns, or to update contact information. Our business hours are Monday – Thursday 8:30am - 4:30pm and Friday 8:30am – 3:00pm.

Sincerely,
Project Oz

Project Oz is committed to meeting the needs of youth and young adults. Answering
these questions will help us better serve you and we will provide immediate help and
referrals when needed. All of your answers are strictly confidential, and a caseworker
is available if you would like to speak with one today.

1.    We provide services to all youth and their families and do not discriminate in any way on the basis of race, gender, national origin, religion, ancestry, age, economic condition, HIV status, sexual orientation, or disability.

2.    Counseling/family therapy is completely voluntary. Every youth and family member has the right to refuse or discontinue services at any time. If you have been court ordered or referred by probation, counseling is still voluntary. However, non-participation and non-attendance will be reported back to the court/probation officer.

3.    Youth and their families have the right to participate — and are strongly encouraged to do so — in the process of developing treatment goals. Family participation is critical to the counseling process when the "identified client" is a child or adolescent.

4.    Youth and families have the right to be fully informed as to all charges and all sources of reimbursement and any limitations placed on treatment by third-party payers (i.e. insurance companies). Project Oz does not charge for services at this time.

5.    Youth and their families have the right to confidentiality. A release of information form must be signed by both the youth and the legal guardian in order to obtain or release information concerning current or past medical, psychiatric, or addiction treatment. Under no circumstances will client names be made available to outside agencies or individuals without a signed release of information.

6.    All youth and their families are encouraged to express opinions and recommendations regarding the treatment process. Any grievance or unusual incident will be handled promptly. A written response, phone call, and/or meeting will be scheduled to address the complaint. Complaints or unusual incidents may be reported to the staff member with whom they are in contact, any manager, or the agency executive director.

7.    My signature below indicates consent which allows my minor child to receive services from Project Oz and their affiliated staff. I understand this consent is effective for 1-year and can be revoked at any time. Furthermore, I understand, in accordance with Illinois Public Act 100-0196, the right of the assigned caseworker to provide counseling services for youth under the age of 17 for up to 8 separate 90-minute sessions without parental or guardian consent. Any services beyond this time frame will require parental or guardian consent.

CONFIDENTIALITY

Federal law and professional ethics require everything discussed in therapy/counseling stay in the strictest confidence. Therefore, Project Oz staff will not provide information to anyone without written permission. There are very few instances when Project Oz staff is required by law to disclose information. These situations include serious threats of homicide or suicide, and reports of physical abuse, sexual abuse, or neglect of a minor. Also, in rare circumstances, Project Oz could be called upon (subpoenaed) to testify in a court of law about you. If the law required Project Oz to do this, we would attempt to discuss any testimony with you beforehand.

I fully understand my rights as explained to me above.

I, {name} hereby authorize the staff of the Transitional Living Program of Project Oz, Bloomington, Illinois to release or obtain information from any of the above agencies and their designated representative, unless otherwise indicated, should this be considered necessary by Project Oz. The Transitional Living Program staff will obtain or release the following information pertaining to the minor’s case: any medical, social, psychological, or educational information significant to the development of the case by the Project Oz staff. I understand that the federal law mandated the confidentiality be maintained and that Project Oz or the receiving agency will not release any information to any other person or agency unless I give written permission. I have the right to inspect and copy the information being discussed. The duration of this release is one year beginning today, {dateOf75} and expiring {selectOne}(select below), unless I notify Project Oz, revoking consent.

This agency participates in the Central Illinois Continuum of Care(CICoC) Homeless Management Information Network. Because this Network is made up of many service providers across the Continuum, you have the option to share part or all of your information with other service providers from which you might be seeking services. This may reduce the time spent answering basic questions
regarding your situation, and allow that agency to focus on meeting your service needs.

The computer program used for this purpose has industry standard security protocols, and is updated regularly to meet these security standards. The information you provide will only be shared with this agency, and any other agency in the network you designate. Information collected is housed in a secure server located at Bowman Internet Systems in Shreveport, Louisiana. Limited staff persons of Bowman Systems have access to this server and the data housed there and but only for network support and maintenance purposes. Data collected for the network will be maintained for seven years from the date of entry and then any inactive record will be permanently deleted from the network.

The agency, from which you are currently receiving services, is the best resource to help you identify which other agencies you may also benefit by receiving services. There is a list on the back of this form with participating providers by community. You may select to have your information shared through the entire network, with only certain communities or only specific agencies.
Please note; if you do not instruct this agency to release your information, no other service provision agency will have access to it. If you do decide to share information at this time and later change your mind, you can revoke this permission in writing at any time and security protections to prevent your information from being viewed by any other service provider will be put into place. The VI-SPDAT (Vulnerability Index and Service Prioritization Decision Assistance Tool) is a quick survey our community uses to help identify what type of housing services will be most helpful to you. Your answers to this tool will be kept in a secure database managed by PATH. Your responses will only be shared with organizations and people named on this signed consent. By signing this
form you are consenting to allow this agency to share your information with this agency, and any other agency in the network you designate.

Agencies participating in the CICoC Coordinated Entry System:

PATH Crisis Center, Salvation Army – Bloomington & Kankakee offices, Regional Office of Education ( IKAN),Home Sweet Home Ministries, Partners for Community Recycling for Families Program, Collaborative Solutions Institute, Bloomington Housing Authority, Children’s Foundation Crisis Nursery, Prairie State Legal Services, Mid-Central Community Action, The Baby Fold, Project Oz, City of Bloomington Community Development Division, Chestnut Health Systems – Bloomington, Catholic Charities – Kankakee& Joliet, Prince Home, Your Family Resource Connection, Kankakee County Community Services, Garden of Prayer Youth Center, Crosspoint Human Services

SIGN BELOW IF AGREEING TO BE INTERVIEWED

We protect personal information we collect about the participant by maintaining physical, electronic, and procedural safeguards. Program participation information will be shared only with authorized staff with a need to know about the participants. Information may also be released as necessary for program evaluation; audit purposes; and certain laws or situations such as child abuse/neglect, threats of harm to self or others, court subpoenas, or certain severe mental health issues. Therefore, I hereby authorize the McLean County Continuum of Care to collect this data as outlined above, use it for the purposes outlined, and store the data electronically. I further understand that the membership of the McLean County Continuum of Care Provider Agencies changes from time to time, and I expressly authorize the information to be shared with any other agency that joins the network, regardless of whether they are
currently listed on this form. A photostatic copy/facsimile of this consent will be as valid as the original. By signing, I also indicate that I received a copy of this form, upon request, and understand program policies. If rules are broken, services may be altered, suspended, or terminated.

THIS RELEASE OF INFORMATION REMAINS IN EFFECT FOR A PERIOD OF 1 YEAR FROM THE DATE OF CLIENT’S SIGNATURE OR until REVOKED IN WRITING.