Intake Form

First Name

Last Name

Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

City

Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

If we cannot get a hold of you, is there another person we can call?

Emergency Contact Name

Emergency Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Relationship to You

Preferred Method of Communication

Do you have Medi-Cal?

Medical CIN#

Who is your Managed Care Plan?

I need...

Child's Name

First NameLast Name

Child's Date of Birth

Date

Child's Medical CIN#

Are you or child enrolled in CCS?

Do you have children with special needs beyond CCS medical condition?

What do you need help with?

For your convenience, please select a date and time when we can contact you to discuss the type of support you need.

Appointment

Signature

Enhance Case Management services population of focus California Children's Services

Disclosure for case management services

I consent to case management services with growing2gether,

Consent for Case Management Services I hereby consent to receive case management services from Growing2Gether. I understand that case management may include assessment of needs, care coordination, referrals to community and, assistance with appointments and paperwork. I understand Growing2Gether cannot communication with service providers on my behalf, however can help (client) communicate by offering conference calls. I understand that: - Participation is voluntary and I may withdraw consent at any time without affecting my access to other services. - Information shared with the case manager is confidential and will be used to provide services, coordinate care, and communicate with other providers as needed. My information may be shared only with my permission or as required by law (for example, in cases of harm to self or others, abuse, or court order). - I may be asked to provide personal and medical information necessary for coordination of services. I agree to the release of relevant information to other agencies and providers as necessary for care coordination. - The case manager will make reasonable efforts to protect my privacy, but confidentiality cannot be guaranteed in all situations. By signing below, I acknowledge that I have read and understand this consent and agree to receive case management services from Growing2Gether.