ACHIEVING BETTER COPING SKILLS LLC
YOUTH INTAKE PACKET
Youth Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Mercy Care Member ID No.
*
previsouly Participant ID (PI No.) or CMDP
Medication Needed?
*
Yes
No
On Probation?
*
Yes
No
Probation/Parole Officer Information
Behavior Concerns
Medical Concerns
Your answers below represent your consent for Achieving Better Coping Skills LLC to exercise the following responsibilities or Activities for the listed Youth:
Click YES or NO for Achieving Better Coping Skills LLC's Consent to the following:
Rows
YES
NO
CONSENT FOR SPORTS: To participate in Sports or Strenuous Activities.
CONSENT FOR MEDICAL TREATMENT: To provide Emergency Dental or Medical Care prescribed by a duly licensed Physician (MD) or Dentist (DDS). This care maybe under whatever conditions are necessary to preserve the Life time or well-being of my dependent.
CONSENT TO TRANSPORT: I consent the youth to be transported by Achieving Better Coping Skills LLC
.
and its component programs using the company vehicles or the staff’s personal vehicles.
YOUTH GRIEVANCE: I agree that the Youth and/or his parents or legal guardian have the right to file a grievance of dissatisfaction with care, treatment or other services they receive from
Achieving Better Coping Skills LLC
. I understand that staff shall not discriminate in any way against any youth or anyone who has participated in an investigative process. I acknowledge receipt of the Achieving Better Coping Skills LLC
.
Policy and Procedures for Youth’s Grievances. I have read the document and staff have answered my questions about its contents. I understand the document and agree to its terms and conditions.
CREATIVE ARTS: Achieving Better Coping Skills LLC
.
uses creative arts as part of our youth building program. I agree to allow the Youth listed above to be exposed to music development seminars or sessions, video filming sets for teaching directing/producing skills in the film industry, and photography lessons to teach the basic and advanced concepts of digital photography. Through the teachings of all three creative art methods, I understand that the youth may be recorded with video, audio devices, or photography for the purpose of teaching creative arts. Such videos and photography may be used within the company for morale building and use on the company website.
CONSENT FOR YOUTH CELLPHONE USE (if applicable per personal item/gifted item)
Youth Responsibilities:
• Alert caregivers when suspicious or alarming phone calls or text messages are received.
• Follow school rules & regulations for cell phones, such as turning them off during class.
• Consider respectful use of the cell phone in different situations, for instance, it may be appropriate to turn the phone on silence, or put the phone away at meal times, while speaking with others, at school, etc.
• Avoid inappropriate use of electronics such as viewing, sending, or receiving pornographic photographs, cyberbullying, etc. If any inappropriate images are received, report them to an adult ally (caregiver, DCS Specialist, Life Skills Trainer, Teacher, etc.) immediately for assistance.
• Follow state and municipal laws regarding cell phone usage while driving, including texting while operating a motor vehicle.
• Utilize the cell phone to assist in positive activities that support the transition to adulthood.
Out-of-Home-Care Provider / DCS Specialist Responsibilities
• Allow the youth to have telephonic communication with their DCS Specialist and other professionals (e.g., guardian ad litem, attorney, court-
appointed special advocate, and clergy) who serve the youth.
• Allow the youth to have telephonic communication with their parents, relatives, and friends except as prohibited by court order or case plan.
Provide support and education to youth around healthy communication via telephone.
• Afford the youth as much privacy as possible.
• Apply reasonable restrictions, such as turning off the phone during home or facility meals or activities, and/or establishing a schedule and rules for telephonic communication.
• Allow youth at any time to use a phone to make a complaint to an appropriate authority about the conditions of their living arrangements, treatment by the provider, safety, well-being (physical or psychological) or any issue deemed problematical by the youth.
• Impose reasonable restrictions, if necessary, on phone usage for disciplinary reasons without effectively denying the youth's right to have telephonic access to friends and family. If it is obvious that a youth's cell phone is placing the child at risk, the phone can be removed as an immediate measure and the DCS Specialist will be notified immediately.
If any answers were clicked NO, please state reason for denial:
DCS Specialist Name
*
First Name
Last Name
DCS Specialist Phone Number
*
Format: (000) 000-0000.
DCS Specialist E-mail
*
example@example.com
DCS Specialist Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
DCS Specialist REGION
Supervisor's Name
First Name
Last Name
Supervisor's Phone Number
Format: (000) 000-0000.
Supervisor's E-mail
example@example.com
As the Legal Guardian of the youth listed above, you agree to your answers above.
DCS Specialist Signature
Date
*
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Month
/
Day
Year
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