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.
- 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.
- Release of Information from Doctor: This document is used to give a doctor approval to release information such as medical protocols, allergy information, and any other medical related information.

Release of Information
I, First Name Last Name , give my permission to Triangle, Inc. to release the information listed below to Person's Name of Agency Name Street Address City State Zip .
Yo, First Name Last Name , doy mi permiso al triángulo, Inc. para liberar
La información que se detalla acontinuación en Person's Name deAgency Name Street Address City State Zip .
This information is to be released for the purpose of
Specific information proposed for release:
Manner in which information will be transmitted (e.g. verbal, written, fax, etc.):
I understand that this release is valid only for the period of one year from the date of my signature and that I may withdraw my consent at any time. The information to be released has been explained to me and I have had the opportunity to ask questions. I give my consent voluntarily, without threat of punishment of 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.
Signature of individual authorizing release

Clear
Date of signature

MonthDayYear
Date
Please note: If you would like us to release information to more than one person, please fill out a form for each person. You can fill out addtional Release of Information forms by clicking the section below titled, "Were you asked to complete an individual form? Click here!" Then click on "Release of Information."
Signature of person obtaining consent

Clear
Date of signature

MonthDayYear
Date

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

Release of Information from Doctor
I, First Name Last Name , give my permission to Name to release the information listed below to Person's Name of Agency Name Street Address City State Zip.
Yo, First Name Last Name, doy mi permiso a Name para divulgar la información que se enumera a continuación a Person's Name deAgency Name Street Address City State Zip.
This information is to be released for the purpose of
Specific information proposed for release:
Manner in which information will be transmitted (e.g. verbal, written, fax, etc.):
I understand that this release is valid only for the period of one year from the date of my signature and that I may withdraw my consent at any time. The information to be released has been explained to me and I have had the opportunity to ask questions. I give my consent voluntarily, without threat of punishment of promise of reward. I have discussed this release with the person obtaining my consent andhave had my questions fully answered. I understand that I may withdraw my consent at any time without fear of punishment.
Signature of individual authorizing release

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

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
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