Individual Receiving Services

First NameLast Name

Location

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Email

example@example.com

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Is this phone number a

Cell Phone?Land Line?

We strive for timely responses for our clients and we often use texting for correspondence. May we text you?

YesNo

Email

example@example.com

Who is the guardian? (First and Last Name)

What is the client's primary diagnosis?

Mileage Policy

In general, our DSPs will provide transportation up to 30 miles per day. For requests and circumstances that exceed 30 miles per day must be approved by Family First in advance.

Cancellation & Scheduling Policy

Cancellations: In the event of cancellations, we kindly request that you notify us at least 24 hours prior to the scheduled service. Exceeding two cancellations within a 30-day period may result in the discontinuation of services. However, exceptions for illness or medical necessity will be considered on a case-by-case basis.

Scheduling: We also want to draw your attention to the importance of scheduling for the continuity of care and staff retention. It is crucial that the schedules created during the intake and meet and greet sessions are maintained. Additionally, we understand that there may be occasions when special accommodations are required for events, personal appointments, or other unique circumstances. In such cases, please reach out to us, and we will do our best to make necessary arrangements.

Furthermore, we accept alterations to the schedule communicated directly with the provider for inclement weather, appointments, or personal commitments. However, any authorized and scheduled hours that are missed during the billing period are expected to be made up. Please coordinate with your provider and contact our office to make appropriate arrangements.

Signature

I/We, the undersigned, as the parent(s) or legal guardian(s) of "the individual," acknowledge and agree to the following terms in consideration of Family First Developmental Disability Solutions LLC's referral of a DSP/BHP:

Waiver of Claims
I/We consent to waive any present or future claims against Family First Developmental Disability Solutions LLC, including its officers, trustees, agents, and employees as individuals.

Indemnification
Family First Developmental Disabilities Solutions is comprehensively insured in compliance with State of Maine requirements as a Home and Community Support Provider, ensuring protection for both clients and staff. I/We agree to indemnify and hold Family First Developmental Disability Solutions LLC harmless from any liability for property damage, loss, or personal injury involving third parties. Any claims will undergo review and adjudication through the company's insurance carrier.

Binding Nature of Agreement
This Agreement is binding on my/our heirs, next of kin, executors, administrators, assigns, and representatives.

Governing Law
This Agreement and all related rights, duties, and obligations are governed exclusively by the laws of the State of Maine.

Jurisdiction
Any legal proceedings concerning this Agreement shall be conducted solely in the State of Maine and under the exclusive jurisdiction of its courts.

Coverage

Family First Developmental Disabilities Solutions is fully insured as mandated by the State of Maine, providing protection for clients and staff/employees.

By signing this document, you confirm that you have read, understood, and agree to the terms and conditions of this Liability Waiver Agreement.

Name

First NameLast Name

Signature

Date

Family Information

Additional Contact/Emergency Contact

Mileage Policy

Cancellation & Scheduling Policy