CM Youth Intake Packet

Step Ahead Enterprises

Case Manager Youth Intake Form
Facility

Taylor HouseKate's PlaceHudson HomePearle's PlaceNevada Home
Youth Name*

First NameLast Name
Date of Birth*

MonthDayYear
Gender

MaleFemale
DCS Case ID*
PID *
Participant ID Number*
Medication Needed?*

YesNo
On Probation?*

YesNo
Probation/Parole Officer Information
Behavior concerns
Medical Concerns
Your answers below represent your consent for Step Ahead Enterprises to exercise the following responsibilities or activities for the listed youth:

Click YES or NO for Step Ahead Enterprises Consent to the following:

	YES	NO
CONSENT FOR SPORTS: To participate in Sports or Strenuous Activities.
CONSENT FOR MEDICAL TREATMENT: To provide Emergency Dental or Medical Care Prescribed by a duly licensed Physcian (MD) or Dentist (DDS). This care may be under watever conditions are necessary to preserve the life time or well-being of my dependent.
CONSENT TO TRANSPORT: I consent the youth to be transported by Step Ahead Enterprises and its component programs using the company vehicles or the staff's personal vehicles.
YOUTH GRIEVANCE:I agree that the Youth and/or his parents or legal guardian have the right to file a grievance of dissatisfaction with care, treatment or other services they receive from Step Ahead Enterprises. I understand that staff shall not discriminate in any way against any youth or anyone who has participated in an investigative process. I acknowledge receipt of the Step Ahead Enterprises Policy and Procedures for Youth’s Grievances. I have read the document and staff have answered my questions about its contents. I understand the document and agree to its terms and conditions.
CREATIVE ARTS:Step Ahead uses creative arts as part of our youth building program. I agree to allow the Youth listed above to be exposed to music development seminars or sessions, video filming sets for teaching directing/producing skills in the film industry, and photography lessons to teach the basic and advanced concepts of digital photography. Through the teachings of all three creative art methods, I understand that the youth may be recorded with video, audio devices, or photography for the purpose of teaching creative arts. Such videos and photography may be used within the company for morale building and use on the company website.

If any answers were clicked NO, please state reason for denial:
Case Manager Name*

First NameLast Name
Case Manager Office Phone Number*

Area CodePhone Number
Case Manager Cell Phone Number*

Area CodePhone Number
Case Manager Email*
Case Manager Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Case Manger REGION*
Supervisor's Name*

First NameLast Name
Supervisor's Phone Number*

Area CodePhone Number
supervisor's E-mail
As the Legal Guardian of the youth listed above, you agree to your answers clicked above.
Case Manager Signature*
Date*

MonthDayYear
Staff Name*

First NameLast Name
Should be Empty:

Step Ahead Enterprises

Your answers below represent your consent for Step Ahead Enterprises to exercise the following responsibilities or activities for the listed youth:

As the Legal Guardian of the youth listed above, you agree to your answers clicked above.