Day Services Intake Forms

What Triangle location do you and/or your loved one attend?*

450 Broadway, Malden493 Main Street (Prism Program), Malden157 Pleasant Street, MaldenRandolphSalem
Definition of Forms
- Release of Information: This form is to be completed by the guardian for anyone you would like for us to speak or disclose any information to (ie. residential providers, family members, medical professionals, etc.).
  - For an individual that is presumed competent (their own guardian), a release must be filled out for parents if you would like for us to speak or disclose any information to them.
  - A form must be filled out for any emergency contact person we have on file, if you would like for us to speak or disclose any information to them.
  - A form must be filled out to give a doctor approval to relesae information such as medical protocols, allergy information, and any other medical related information.
- Authorization for Emergency Medical Treatment: This needs to be completed by the guardian.
  - If an individual is presumed competent, they need to sign/complete this form.

Authorization for Emergency Medical Treatment
I, First Name Last Name give Triangle, Inc. my permission to perform First Aid/CPR and or obtain medical assistance in the event that Name becomes injured or becomes ill.
Yo, First Name Last Name doy a Triangle, Inc. mi permiso para realizar primeros auxilios/RCP y/o obtener asistencia médica en caso de que Name se lesione o se enferme.
I give my consent voluntarily, without threat of punishment or promise of reward. I have discussed this release with the person obtaining my consent and have had my questions fully answered. I understand that I may withdraw my consent at any time without fear of punishment.
Individual's signature

Clear
Date

MonthDayYear
Date
Guardian's signature (if necessary)

Clear
Date

MonthDayYear
Date
Signature of person obtaining consent

Clear
Date

MonthDayYear
Date

Emergency Fact Sheet Information
Height
Weight
Build
Hair color
Eyes
Relevant emergency medical information (allergies, medication needs, physical limitations, etc.)
Emergency Contact Person #1
Emergency Contact #1 Telephone
Emergency Contact #1 Email
example@example.com
Do you have additional emergency contact people?

YesNo
Emergency Contact Person #2

First NameLast Name
Emergency Contact Person #2 Phone Number
Relationship to Emergency Contact Person #2
Emergency Contact Person #2 Email
example@example.com
Emergency Contact Person #3

First NameLast Name
Emergency Contact #3 Phone Number
Relationship to Emergency Contact Person #3
Emergency Contact #3 Email
example@example.com
Physician's Name
Physician's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician's Telephone
Language/Communication
Ability to Protect Self
Significant Behavioral Characteristics
Likely to Respond to Search Efforts
Places Frequented
Pattern of Movement if Lost
Relevant Capabilities, Limitations, Transportaion Skills, and Preferences
Probable Dress

Medications List
Please list all medications both over the counter as well as prescription drugs. Please fill in all fields.
If no medications are being taken, please check the box below.

None

Medication #1

	Answer
Name of medication
Reason taking medication
Dosage

Medication #2

	Answer
Name of medication
Reason taking medication
Dosage

Medication #3

	Answer
Name of medication
Reason taking medication
Dosage

Medication #4

	Answer
Name of medication
Reason taking medication
Dosage

Medication #5

	Answer
Name of medication
Reason taking medication
Dosage

Medication #6

	Answer
Name of medication
Reason taking medication
Dosage

Medication #7

	Answer
Name of medication
Reason taking medication
Dosage

Medication #8

	Answer
Name of medication
Reason taking medication
Dosage

NOTE: Please be aware that Triangle does not currently have a nurse on site, so all medications must be self-administered. We cannot assist someone in taking medications. If you have questions about this, please contact Drew Warren at 781-388-4308.

Participant Information Form
Name
Date of Birth

MonthDayYear
Date
Sex

MaleFemale
Age
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number
Residential Provider (if applicable)
Residential Provider Phone
Race

African AmericanCaucasionNative AmericanAsian/Pacific IslanderLatino/HispanicOther
Disability/Disabilities

Instructions: In the table below, mark as follows:
- 1 in the row for primary diagnosis
- 2 for secondary diagnosis
- + for any additional diagnoses.

Mental Health

	Answer
Adjustment Disorder
Anxiety Disorder
Bipolar Disorder
Depression
Borderline Personality
Psychosis
Schizophrenia
Other (please write in)

Disabilities

	Answer
Developmental Disorder
Learning Disorder
Developmentally Delayed
Traumatic Brain Injury (TBI)
Autism
Asperger's
Cerebral Palsy
Seizure Disorder
Hard of Hearing
Deaf
ADD
Spinal Cord Injury
Visually Impaired
Other (please write in)

Educational Level

Up to 8th grade9th-12th gradeGEDCertificate of CompletionHigh school diplomaSome collegeCollege degreeMasters +Other

Guardianship Verification
I, First Name Last Name , am my own guardian and I am responsible for managing my own medical legal and financial decisions
Yo, First Name Last Name , soy mi propio tutor y soy responsable de gestionar mis propias decisiones médicas, legales y financieras.
Name has been deemed incompetent by the probate court to manage decisions in the following matters: Medical Legal Financial
Name ha sido declarado incompetente por el tribunal sucesorio para gestionar decisiones en las siguientes materias:
Médico Legal Financiero
I/We,Guardian Name have been appointed guardian of Name.
Yo/nosotros,Guardian Name hemos sido designados tutores de
Name.
A copy of the Guardianship Decree (not the Petition for Guardianship) must be attached to this form for the individual's file. Please upload it here.

Cancelof
Signature of Self (if own guardian) or Guardian #1

Clear
Date

MonthDayYear
Date
Relationship to Guardian #1
Guardian #1 Address
Guardian #1 City
Guardian #1 State
Guardian #1 Zip Code
Guardian #1 Home Phone
Guardian #1 Work/Cell Phone
Do you have more than one guardian?

YesNo
Signature of Guardian #2

Clear
Date

MonthDayYear
Date
Relationship to Guardian #2
Guardian #2 Address
Guardian #2 City
Guardian #2 State
Guardian #2 Zip Code
Guardian #2 Home Phone
Guardian #2 Work/Cell Phone
Signature of Guardian #3

Clear
Date

MonthDayYear
Date
Relationship to Guardian #3
Guardian #3 Address
Guardian #3 City
Guardian #3 State
Guardian #3 Zip Code
Guardian #3 Home Phone
Guardian #3 Work/Cell Phone

Media Consent Form
Permission for Release of Photographs/Video Images - 115 CMR 5.04(2)
SECTION I. Personal Information:
Individual's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Triangle Location
SECTION II. Permission to Use Images:
- Check the first box to give Triangle, Inc. permission to use one or more photos of you.
- Then, check Box A. if you wish to give Triangle, Inc. ongoing permission to use any images of you.
- Or check Box B. if you only wish to give Triangle, Inc. permission to use one or more specific images of you.
- You may check both A. and B. if you wish to give Triangle, Inc. permission to use both specific images of you and ongoing permission to use any images of you.
Permission to Use Images: check here if you'd like to give permission to use photos!

I am providing my permission for the ongoing use or disclosure of photographs, and images taken of me (or the individual for whom I am guardian) and that Triangle, Inc. does not have to obtain my permission for additional uses of my image(s) and/or information that I have authorized above during the term of this Permission for Release.
Options to Use Images: check either A, B, or both!

A. I hereby provide my permission to Triangle, Inc. to use any photographic image(s) and/or video(s) of me for the following purposes: on Triangle. Inc.’s digital and printed marketing material to promote Triangle, Inc.B. I hereby provide my permission to Triangle, Inc. to use specific photographic image(s) and/or video(s) of me (email attached image) for the purposes listed below.
Images may be used for the following purposes:
- Posting to the Triangle, Inc. Website and/or Social Media Accounts (e.g. Facebook, Twitter, Instagram, etc.).
  - Note: social media posts may include personal information identifying me by name. By checking this box, you acknowledge that image(s) and/or video(s) posted on the internet can be viewed and downloaded by others and that social media posts may be shared or re-tweeted by other accounts once posted by the Triangle, Inc. and you hereby consent to the same.
- Informational Brochures or Pamphlets
- Photographic or Video Presentations for Public Display
- Photographic or Video Presentations with Personal Information for Public Display
- Other
SECTION III: Written Consent
I understand that I can change my mind and cancel this permission at any time, but that such cancellation is forward-looking only, and will not affect information I already permitted to be released. If I revoke my permission, I must do so in writing and present it to the Triangle, Inc., staff or office authorized to use or disclose my images or information by this Permission for Release. I understand that once the above image(s)/information is/are disclosed, recipient(s) may re-disclose it and the material may not be protected by federal or state privacy laws or regulations. I understand my consent to the use or disclosure of my image(s) or information is voluntary and I do not need to sign this form to continue to receive services from Triangle, Inc.

Questions? Contact Kassi Soulard, Development at ksoulard@triangle-inc.org
Signature of Individual or Guardian

Clear
Date

MonthDayYear
Date
Full Name

First NameLast Name
Identify legal authority if signed by Guardian or other Legally-Authorized Representative
My consent will expire Date (date or event - must not exceed one year).

Save, Preview, and Submit
Please enter an email address here if you'd like to receive confirmation that this form was submitted successfully and a copy of this form.
example@example.com
Should be Empty:

Permission for Release of Photographs/Video Images - 115 CMR 5.04(2)

SECTION III: Written Consent