PHSNC REFERRAL & CONSENT FOR SERVICES FORM

  • PHSNC REFERRAL & CONSENT

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  • Referral Area*
  • Have you had a Clinical Assessment in the pass year?*
  •  - -
  • Primary Language*
  • Preferred Pronouns*
  • Format: (000) 000-0000.
  • Homeless?*
  • Format: (000) 000-0000.
  • Are you currently seeing a Therapist?*
  • Format: (000) 000-0000.
  • Are you currently on probation or parole?*
  • Format: (000) 000-0000.
  • Are you experiencing or have you ever experienced any of the following*
  • Client reported Current/Previous Known Diagnosis*
  • Current Known Diagnosis*
  • Housing- what is the client's current housing situation? select the option that applies most*
  • Transportation- what is the client's current transportation status? select the option that applies most*
  • Employment- what is the client's current employment status? select the option that applies most*
  • Education- what is the client's current education status? select the option that applies most*
  • Money Management- what is the client's current Money Management status? select the option that applies most*
  • General/Mental Health - what is the client's current General/Mental Health status? select the option that applies most*
  • Legal - what is the client's current Legal status? select the option that applies most*
  • If you qualify for assistance how many hours (1-5) per week do you need to help reach your goals?*

  • PHILA Health Systems of NC Consent for Treatment

     I hereby give my informed consent for the individual identified above to receive treatment from PHILA Health Systems of NC and to participate in treatment programs provided by PHILA Health Systems of NC. I understand that this consent will be valid until it is withdrawn by me or the client listed above is discharged from treatment.

  • I understand that the service/treatment will consist of my enrollment in the following recommended services.*

  • I understand that I will be informed of any changes in the service/treatment service, program, and/or staff assignments. I have the right to agree or disagree to any referrals for this service or any other that may arise in the future prior to the above named individual being placed in any service or program, except in emergency situations.

    I understand that there are alleged benefits, potential risks, and possible alternative methods of treatment and I may discuss these with agency staff at any time before, during, and after treatment.

    In the case of accident or illness while the above named individual is receiving service/treatment from PHILA Health Systems of NC, I give my consent for the staff to provide and/or obtain emergency medical treatment.

    I authorize PHILA Health Systems of NC staff to provide transportation as deemed necessary.

    I fully understand the statements above. This form has been read an explained to me. I may make any concern and/or complaint that I may have regarding treatment by writing to the following address:

     

    PHILA Health Systems of NC

    Attn: Clinical Supervisor

    1 Buffalo Ave NW Ste 2207

    Concord, NC 28025

    I may also request a meeting to discuss my concerns and/or complaints by writing the Clinical Supervisor at the address above. I understand that the Clinical Supervisor will convene a meeting to hear my concerns and/or complaints and settle any issues that may need resolution.

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  • PHSNC CLIENT APP

    Take time to have the client scan the QR code to download our client portal to their mobile device
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