Consent for Services: This treatment consent form covers all procedures that are not of a nature to require a special consent, and it provides protection for the procedures performed by the professional staff of Jewish Family & Career Services. This form documents that the client has consented to treatment at Jewish Family & Career Services, including but not limited to geriatric care management. This allows the professional staff at Jewish Family & Career Services to provide services to you.

This form provides evidence that no guarantee is made by any professional at Jewish Family & Career Services, concerning the outcome of geriatric care management services. There is no guarantee that geriatric care management will be successful. This form also provides evidence that consent is given only after a full explanation has been provided by the staff at Jewish Family & Career Services. If you have any questions concerning this or any other matters, it is your responsibility to ask your geriatric care manager. By signing this form, you acknowledge that you understand your consent to treatment as explained in this form.

I, (Print your name above), do hereby voluntarily consent to care and treatment by provided by

, his/her assistants and/or designees. I am aware that the services a geriatric care manager are not an exact science and I acknowledge that no guarantees have been made as to the result of evaluation or treatment.

I am aware that I am an active participant in the geriatric care management process. My responsibilities in treatment include informing my geriatric care manager of any information that may be relevant to the problems or conditions being addressed, assisting with the development of a care plan, following my geriatric care manager’s advice to the best of my ability, and ending my relationship with my geriatric care manager in a responsible way.

If I am consenting to treatment for another person, I certify that I am legally responsible for that person and am entitled to consent to treatment for them.

This form has been fully explained to me and I certify that I understand its contents. I also understand that it is my sole responsibility to ask any questions or obtain any clarification necessary to my understanding this form fully.

*Your credit card will be charged

hours of geriatric care management  services. Your credit card will be charged prior to services being provided. You will receive an invoice in the mail for the charges. JF&CS accepts payment by credit card (not American Express) or check.

Invoice should be sent to:

for the Geriatric Care Management

Services provided by JF&CS described in this contract by signing my name below.