Application for Services
Name
*
DOB
*
MM/DD/YYYY
Gender
Male
Female
Other
Address
*
Phone Number
*
Alternate Phone Number
Race
White/Caucasian
Black/African American
American Indian/Alaskan Native
Asian
Native Hawaiian or Other Pacific Islander
Two or More Races
Some Other Race
Prefer not to Answer
Ethnicity
Hispanic or Latino
Non Hispanic or Latino
Other
Prefer not to Answer
SSN
*
Medicaid #
Email
example@example.com
School
Primary Care Doctor
Services Requested
Case management
Parent or Guardian Name
Parent/Guardian Phone Number
Parent or Guardian Address
Preferred communication:
Email
Phone
Text
Mail
Developmental Disability Diagnosis
Medical or Psychiatric Diagnosis
Accommodations or assistive devices
How did you hear about us?
Applicant’s signature
Parent/ Guardian Signature
Our Mission: To serve our community with compassion, innovation and transparency
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Consent for Release of Information
The following agency(s) have my permission to exchange/give/receive/share/re-disclose information regarding service delivery planning for the purpose of securing, coordinating, and/or providing services for the above-named person:
All Agencies Listed
Head Start (HAPCAP)
Athens County Childrens Services
Integrated Services (ISBH)
Help Me Grow
Athens Co DJFS
OhioHealth
Nelsonville-York City Schools
Federal Hocking Local Schools
Marietta Memorial
Health Recovery Services
Athens City Schools
AHV 317 Board
Hopewell Health Centers, Inc.
Family & Children First Council
Sojourner's Care Network
Trimble Local Schools
New Story
Athens Co Juvenile Court
Department of Youth Services
Nationwide Children's Hospital
Athens Co Health Department
Athens/Meigs ESC
Holzer Health Systems
OOD
Alexander Local Schools
Tri County Career Center
Other
I authorize sharing of the following information if needed by the receiving agency to secure, coordinate, and provide services to the individual (circle yes or no and initial):
Identifying Information: Name, birth date, sex, gender identity, race, address, telephone number, and social security number.
Yes
No
Case Information: The above identifying information, plus medical (except for HIV, AIDS, and drug and alcohol treatment records) and social history, treatment/service history, psychological evaluations, Individualized Education Plans (IEPs), Individualized Family Service Plans, transition plans, vocational assessments, grades and attendance, and other personal information regarding me or the individual named above (disability, type of services being received and name of agencies providing services to me or the individual named above). Information regarding the following shall not be released unless initialed below:
Yes
No
HIV and AIDS related diagnosis and treatment.
Yes
No
Mental health diagnosis and treatment, including medications.
Yes
No
Substance abuse diagnosis and treatment.
Yes
No
Financial Information: Public assistance eligibility and payment information provided for establishing eligibility including, but not limited to, pay stubs, W2s, and tax return and other financial information as needed.
Yes
No
I understand that the Consent for Release of Information expires 365 days from the date it is signed unless otherwise indicated herein by the consumer. I also understand that I may cancel this Consent for Release of Information at any time by stating so in writing with the date and my signature and delivering it to ACBDD or by notifying by telephone, fax, cell phone, or email. The revocation does not include any information which has been shared between the time that I gave my permission to share information and the time that it was cancelled. I understand that my signing or refusing to sign this consent will not affect public benefits or services that I am entitled to, but it may affect services which I am eligible for. I understand the information obtained will be entered and stored into an internet based, secure data system, not accessible to the public. I also understand that my team may choose to utilize a communication application that is phone based, secure, and not accessible to the public. All data obtained will be essential to intersystem service coordination per Athens County Board of DD. (Initial Below)
(Type Initials)
This consent expires (please check one):
One year from the date signed
Until case closure
Today's Date
-
Month
-
Day
Year
Date
Signature of Witness/Agency Representative
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