Parent/Guardian Consent Form
I hereby give consent for my child(ren) to receive OhioRISE Behavioral Health Respite services from Amazing Home Care Providers LLC. Additionally, I provide my consent for a referral to have a CANS assessment completed to determine eligibility.
Do you consent to the above information?
*
Please Select
Yes
No
1) Youth Name
*
First Name
Last Name
Youth Date of Birth
*
-
Month
-
Day
Year
Date
Youth Medicaid Number
*
2) Youth Name
First Name
Last Name
Youth Date of Birth
-
Month
-
Day
Year
Date
Youth Medicaid Number
3)Youth Name
First Name
Last Name
Youth Date of Birth
-
Month
-
Day
Year
Date
Youth Medicaid Number
4) Youth Name
First Name
Last Name
Youth Date of Birth
-
Month
-
Day
Year
Date
Youth Medicaid Number
Please list the county where the child lives.
*
Must live in Ohio
Please list who referred you?
*
Please select the type of Medicaid insurance your child(ren) have.
*
Please Select
Buckeye
Humana
Anthem Blue Cross Blue Shield of Ohio
AmeriHealth Caritas Ohio
CareSource
Molina
United Health Care
Straight Medicaid
Please list the best time to call you. Please list a few different days and your availability for each.
*
The Assessment will be completed over the phone, please allow up to one hour.
Please list any allergies, health conditions, or special diets that your child or children may have. You may also list any addtional information that you would like us to know.
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Emergency Contact:
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First Name
Last Name
Emergency Contact Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Relationship to the Child or Children:
*
Signature
*
Parent/Guardian Name: Print
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Should be Empty: