Case Management Consent Form

Case Management Consent Form

Formulaire de Consentement pour la Gestion de Cas
Client Information

Information sur le Client
Name / Nom*

First Name/PrénomLast Name/Non de Famille
Date of Birth/Date de Naissance*

MonthDayYear
Date
Current Address*

Street Address/Adresse de la rue or N/A

Line 2 or N/A

City/VilleState / Province

Zip Code/Code Postal
Contact Number/Numéro de Contact
Please enter a valid phone number.
Email
example@example.com
What do you need help with?/ Quel est votre besoin?*
Are you homeless or at risk of becoming homeless? Etes-vous sans abris our en risque de le devenir?*

YesNo
Name of Agency or Establishment in charge of the case / Nom de l'agence ou de l'établissement chargé du cas
Contact Person / Personne de contacte

First NameLast Name
Phone Number
Le numero de telephone de la personne chargee de votre cas
Name and Number of any other person involved in this case / Nom de tout autre personne impliquée dans ce cas.
Informed Consent/ Consentement Avise:

I, the undersigned, understand that COCOMPTS' Case management services is limited to Advocacy and Support, Service Referrals, Cultural brokerage and interpretation. I understand that COCOMPTS not provide legal counsel nor representation. I have had the opportunity to ask questions, and my questions have been answered to my satisfaction.

Je, Sousigne(e), comprends qu'a COCOMPTS les services de gestions des cas sont limites a l'activisme et soutien, l'orientation, la mediation culturelle et l'interpretation. Je comprends que COCOMPTS n'offre pas de conseil ou representation juridique.

Consent for Services/Consentement aux Services:

I voluntarily consent to COCOMPTS' case management services as described above. I understand that I have the right to refuse or stop this service at anytime.

Je consens volontairement aux Services COCOMPTS de gestion de cas tels que decrits ci-haut. Je comprends que je suis en droit de refuser ou d'interrompre ces services a n'importe quel moment.

Authorization for Release of Information/Autorisation de divulgation d'informations:

I authorize the release of information regarding my case to the necessary providers, institutions or agencies involved in my case.

J'autorise la divulgation des informations concernant mon cas aux prestataires de services, institutions ou etablissements necessaires impliques dans mon cas.
Date

MonthDayYear
Date
Signature

Clear
Should be Empty:

Case Management Consent Form

Client Information