MAC Intake Packet
Participant Information
Participant Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Today's Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent / Legal Guardian
*
First Name
Middle Name
Last Name
Full Legal Name
*
First Name
Middle Name
Last Name
Preferred Name / Nickname
Age
*
Gender
*
Pronouns
*
Diagnosis / Disability
*
School / Day Program
*
Street Address
*
City
*
County
*
Zip
*
Parent / Guardian Contact Information
Parent / Legal Guardian (Primary) - Full Name
*
First Name
Middle Name
Last Name
Parent / Legal Guardian (Primary) - Relationship to Participant
*
Parent / Legal Guardian (Primary) - Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent / Legal Guardian (Primary) - Email
*
example@example.com
Parent / Legal Guardian (Primary) - Best time / way to reach you
Second Parent / Guardian - Full Name
First Name
Middle Name
Last Name
Second Parent / Guardian - Relationship to Participant
Second Parent / Guardian - Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Second Parent / Guardian - Email
example@example.com
Funding Source and Emergency Contacts
Funding Source
*
NOW Waiver (Participant Direction)
COMP Waiver (Participant Direction)
Family Support Funding
Direct Private Pay
Other
Funding Source - Other / details
Emergency Contact #1 - Name
*
First Name
Middle Name
Last Name
Emergency Contact #1 - Relationship
*
Emergency Contact #1 - Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact #2 - Name
First Name
Middle Name
Last Name
Emergency Contact #2 - Relationship
Emergency Contact #2 - Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Form 1 Acknowledgment
Parent / Legal Guardian Signature
*
Parent / Legal Guardian Print Name
*
First Name
Middle Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Relationship to Participant
*
Services, Location, and Schedule
Services MAC Provides
*
After-school care
Weekend care
Date-night respite
Overnight care
Job coaching
Community inclusion
Other
Where Do You Want Services Provided
*
In the Participant's home
In the community (parks, outings, errands)
At a MAC-designated location
Other
Where Services Are Provided - Other / Details
Schedule & Frequency - Anticipated Days / Times
*
Schedule & Frequency - Start Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Service Agreement Acknowledgment
Parent / Legal Guardian Signature
*
Parent / Legal Guardian Print Name
*
First Name
Middle Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Relationship to Participant
*
MAC Representative Signature
*
MAC Representative Print Name
*
First Name
Middle Name
Last Name
MAC Representative Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
MAC Representative Time
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
MAC Representative Title / Role at MAC
*
Liability Release
Liability Release Initial Box 1
*
Liability Release Initial Box 2
*
Liability Release Initial Box 3
*
Liability Release Initial Box 4
*
Liability Release Initial Box 5
*
Liability Release Initial Box 6
*
Liability Release Acknowledgment - Parent / Legal Guardian Signature
*
Parent / Legal Guardian Print Name
*
First Name
Middle Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Relationship to Participant
*
Liability Release - MAC Staff Witness
*
First Name
Middle Name
Last Name
Liability Release - Date received
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Medical Information
Primary Care Physician
*
First Name
Last Name
Practice / Clinic
Physician Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Hospital / ER
Insurance Provider
Member / Policy #
Allergies
Current Medical Conditions
Current Medications
Special Instructions (Emergency Medical)
Emergency Medical Authorization
Emergency Medical Authorization Options
*
Call 911 / emergency services if needed
Transport the Participant to the nearest emergency facility if 911 is not warranted but care is needed
Consent to emergency medical treatment, including administration of emergency medications, if I cannot be reached
Share relevant medical information from this form with emergency personnel
Emergency Medical Authorization - Parent / Legal Guardian Signature
*
Parent / Legal Guardian Print Name
*
First Name
Middle Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time
*
Hour Minutes
AM
PM
AM/PM Option
Relationship to Participant
*
Medication Authorization
Medication Handling Method
*
OPTION A — MAC will provide MEDICATION REMINDERS ONLY
OPTION B — NO medications during MAC services
Medication 1 Name & Strength
Medication 1 Dose
Medication 1 Time(s)
Medication 1 Reason / Notes
Medication 2 Name & Strength
Medication 2 Dose
Medication 2 Time(s)
Medication 2 Reason / Notes
Medication 3 Name & Strength
Medication 3 Dose
Medication 3 Time(s)
Medication 3 Reason / Notes
Medication 4 Name & Strength
Medication 4 Dose
Medication 4 Time(s)
Medication 4 Reason / Notes
Medication Special Instructions
Medication Authorization & Acknowledgment - Parent / Legal Guardian Signature
*
Parent / Legal Guardian Print Name
*
First Name
Middle Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Relationship to Participant
*
Medication Receipt Log - Medications received by
First Name
Middle Name
Last Name
Medication Receipt Log - Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Medication Receipt Log - Time
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Transportation Authorization
Transportation Method Options
*
OPTION A — MAC staff may transport in their PERSONAL VEHICLE
OPTION B — MAC may transport in a MAC-OWNED VEHICLE only
OPTION C — NO transportation by MAC
Where MAC May Transport - Destinations
*
Community outings (parks, library, community events)
Errands (grocery, pharmacy, retail)
Restaurants / food outings
Medical appointments (only with specific parent authorization per appointment)
School pickup / drop-off
Other
Where MAC May Transport - Other / Details
Transportation Safety Requirements Initials 1
*
Transportation Safety Requirements Initials 2
*
Transportation Safety Requirements Initials 3
*
Transportation Authorization - Parent / Legal Guardian Signature
*
Parent / Legal Guardian Print Name
*
First Name
Middle Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Relationship to Participant
*
Behavioral Support Authorization
Triggers & Warning Signs
*
Calming & De-escalation Strategies That Work
*
Communication
Use de-escalation strategies
Remove triggers/change environment
Call Parent/Guardian
Call emergency services
Other/additional steps
Physical Intervention Understanding
*
I understand and agree to MAC's de-escalation-first approach
I have reviewed and approve the Participant's Individual Support Plan (ISP) if one exists, and a copy is on file with MAC
Restrictions (Behavioral Support)
Parent / Legal Guardian Signature
*
Print Name
*
First Name
Middle Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Relationship to Participant
*
HIPAA Authorization and Privacy Notice
Privacy Notice Acknowledgment Initial
*
Person / Organization #1 Name
*
First Name
Last Name
Person / Organization #1 Relationship / Role
*
Person / Organization #1 Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Person / Organization #2 Name
First Name
Last Name
Person / Organization #2 Relationship / Role
Person / Organization #2 Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Person / Organization #3 Name
First Name
Last Name
Person / Organization #3 Relationship / Role
Person / Organization #3 Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Types of Information Authorized
*
Service schedules, progress notes, and incident reports
Medical information, medications, and allergies (limited to what is necessary)
Behavioral support information and crisis plan
Billing and funding information
Parent / Legal Guardian Signature
*
Print Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Relationship to Participant
*
Photo / Media Release
Photo / Media Release Consent
*
I DO NOT consent to any photos, videos, or audio recordings of the Participant for any purpose other than internal MAC records.
I consent to photos/videos for INTERNAL MAC use only (staff training, internal records, never published).
I consent to photos/videos for MAC's WEBSITE, with face NOT visible (back-of-head, hands, silhouettes only).
I consent to photos/videos for MAC's WEBSITE AND SOCIAL MEDIA, including the Participant's face.
I consent to the Participant's FIRST NAME being used alongside their image.
Photo / Media Release Conditions Initials 1
Photo / Media Release Conditions Initials 2
Parent / Legal Guardian Signature
*
Print Name
*
First Name
Middle Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Relationship to Participant
*
Submit
Submit
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