CFS Service Acknowledgment

CFS Service Acknowledgment — Open Grace LLC

Please provide your information and consent to proceed with services.
Client and Family Information
Client Full Legal Name

First NameMiddle NameLast Name
UCI Number
Date of Birth

MonthDayYear
Date
Primary Language Spoken
Guardian or Authorized Representative Full Name

First NameMiddle NameLast Name
Relationship to Client
Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Guardian Email Address
example@example.com
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City
State
ZIP Code
Emergency and Safety Information
Emergency Contact Full Name

First NameMiddle NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Client
Known medical conditions staff should be aware of
Known allergies (food, medication, environmental)
Behavioral considerations or known triggers
Preferred hospital in case of emergency
Does the client have an active behavioral support plan?
Does the client have an active safety plan?
IRC Service Coordinator
IRC Service Coordinator Full Name

First NameMiddle NameLast Name
Service Coordinator Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Service Coordinator Email Address
example@example.com
Regional Center Office
Service Acknowledgments
Vendorized CFS Provider Acknowledgment
Service Authorization Acknowledgment
Consent to CFS Services
Service Documentation Acknowledgment
Service Record Review Acknowledgment
Withdrawal of Consent Acknowledgment
Consumer Rights Acknowledgment
Mandated Reporting Acknowledgment
HIPAA and Privacy
Authorization and Privacy Acknowledgments
Photo Release
Authorize photographs for internal documentation only?
Authorize photographs for internal training materials only?
Signature
By signing below I confirm I am the client or legally authorized representative. I have read understood and agree to all acknowledgments in this form.
Guardian Full Name (Print)

First NameLast Name
Relationship to Client
Digital Signature
Date

MonthDayYear
Date
Should be Empty:

CFS Service Acknowledgment — Open Grace LLC

Client and Family Information

Emergency and Safety Information

IRC Service Coordinator

Service Acknowledgments

HIPAA and Privacy

Photo Release

Signature