FY25 Local Care Team Parent/Guardian Consent Form

Local Care Team Parent/Guardian Consent Form

**This form includes Local Care Team Consent Form, LCT/IPC 10-Day Waiver and Confidentiality Statement.**
I (we) understand that information obtained by the Caroline County LCT will be used for assessment, evaluation, and planning for the delivery of services for my/our child. The information to be obtained may include records pertaining to: medical, developmental, psychiatric, social and juvenile services history.

I(we) understand that by law, I (we) need not consent to the release of this information. However, I (we) choose to do so willingly and voluntarily for the purpose specified above. Authorization expires six months from the date of signatures. I (we) understand that I (we) may revoke this consent at any time except to the extent that action has been taken in reliance on my (our) consent.

I (we) give permission for the following agencies to obtain/release/share information regarding:
Name of Child/Youth referred*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Please provide the LCT with permission to share information with participating Team members. Please check all boxes unless you DO NOT want a specific agency to participate in information sharing. I (we) understand that by checking the boxes below and signing this document we are giving permission for the agencies/entities below to share information. Please uncheck any agencies/entities that you do not wish to be included.*

LCT CoordinatorCaroline County Public SchoolsCaroline County Department of Social ServicesCaroline County Department of HealthDepartment of Juvenile ServicesDevelopmental Disabilities Administration/DORSMid Shore Behavioral Health (Core Service Agency)Peer Support/Family Advocate/Family NavigatorLocal Management BoardGovernor's Office for ChildrenSante Affiliated Mobile CrisisTherapist/Behavioral Health ProviderOther
Local Care Team - LCT/IPC 10 Day Waiver

The Local Care Team (LCT) is a forum for interagency discussions and problem solving for individual child and family needs and systemic needs. Although the LCT does not make residential placement decisions nor is LCT approval required for residentials placements, in the course of the interagency discussions, an out-of-State residential placement may be explored, resulting in the LCT making a recommendation to the Lead Agency that a residential placement be considered. The Interagency Placement Committee (IPC) reviews applications from Lead Agencies for funding of the residential placement of children with disabilities into residential facilities out of the State. The IPC may approve, modify, or reject the application as submitted. In accordance with Maryland law (Maryland Human Services Article, Section 8-409 parents and attorneys are entitled to written notification at least ten (10) days prior to any meeting of the LCT or IPC in which their child/client's out-of-State placement is discussed.If you waive your right to a full ten (10) days notice (by signing below), the review of your child/client's case may be expedited. You must provide a working phone number for your case to be expedited, so that you may be notified of the meeting. In the event, you will be notified in writing of any decisions of the LCT and/or IPC concerning your child's placement.

If you do not sign this form, your child/client's case will be reviewed by the LCT and/or IPC after providing ten (10) days written notice to you.

This waiver will expire six months from the date of the parent/guardian/attorney's signature. This waiver may be rescinded prior to this expiration date by submitting a written letter to the Lead Agency of the intent to withdraw this waiver. The date of Lead Agency's receipt of this letter will be effective date of the termination of this waiver; the Lead Agency is responsible for notifying the LCT and/or IPC in writing of any waivers withdrawn for LCT and/or IPC cases.
I wish to be notified in advance of the date of the Local Care Team or State Coordinating Council meeting to discuss my child/client. I have had an opportunity to review and discuss this form with my child/client's case manager. I do not need ten (10) days written notice for the (please check the appropriate box below)*

LCT and IPC meetingsLCT meeting onlyIPC meeting only
I (we) understand that after our initial meeting with the LCT, we are welcome to attend the regularly scheduled LCT Meeting for updates. Regular meetings are held on the third Wednesday of each month. Updates are scheduled last on the agenda and begin at approximately 2:30 pm. If I/we are not able to attend, I/we give permission for updates to be shared with the Local Care Team at regularly scheduled meetings when we are unable to attend:*

I want to be contacted to participate in update meetings. However, I give permission for agencies to share updates with each other if I am unable to attend.No, I do not give permission for updates to be shared unless I am present at the meeting.
I (we) acknowledge any oral or written information exchanged between me/we and Local Care Team representatives is confidential information.
Parent/Guardian/Attorney Signature*

Powered by Jotform SignClear
Parent/Legal Guardian Name Printed*
Email*
example@example.com
Youth/Client (if over 18 years of age) - Please Sign and Print Name
Signature

Powered by Jotform SignClear
Signed on this date:*

MonthDayYear
Date
Should be Empty: