Application / Preliminary Assessment

Applicant General Information

Date

Individual’s Full Name - Last

First

Middle

Social Security No.

Phone No.

Work Phone

Birth Date

Age

Birthplace

Home Address

City

State

Zip

Mailing Address (if different)

City

State

Zip

Race
White/Caucasian
Black/African American
American Indian
Asian or Pacific Islander
Other

Family Information

Father

Mother

Siblings

Other (Grandparents, Aunts, Uncles, Cousins)

Next of Kin Name

Phone

Work Phone

Address

City

State

Zip

Legal Information

Does Applicant have a Court-Appointed Guardian?
Yes No

Adjuticated Incompetent?
Yes No

Will
Yes No

Other Legal

Legal Status
Competent Incompetent

Criminal Justice Status
N/A Court Date Pending Probation Parole

Gender

Citizenship

Religious Preference

Education

Special Education
Yes No

Age Began School

Years Completed
Less than High School
Some High School
High School Graduate
Some College
College Graduate
Unknown

Communication

Communication Methods
Verbal - English
Verbal - Other
Sign Language/Gestures/Device
Other

Hearing Impaired?
Yes No

Primary Diagnosis

Does Applicant have any psychiatric, medical or behavioral needs?
Yes No

Admissions

Person Requesting Admission

Relationship to Applicant

Reason for Request

Financial Resources

Amount - enter dollar amount

Does the individual have a representative Payee?
Yes No

Medical Insurance

Medicaid
Yes No

Medicare
Yes No

MCO Member No.

MCO Group ID No.

Other Medical Insurance?
Yes
No

Allergies
Food
Medication
Environmental

List any special interest, hobbies and/or positive reinforcers

List any goals the individual would like to work on

Skills and Behaviors Checklist

Please click each one and choose the appropriate option:
Eating

Toileting

Room Cleaning

Table Clearing

Sense of Time

Mobility

Dressing

Care of Personal Belongings

Writing

Job Complexity

Grooming

Socialization

Communication

Sense of Direction

Attention Span

Reading

Numbers

Maladaptive Behavior

Individual Screening Documentation Sheet

Name of Person Requesting Service

Title

Presenting Needs Including Situation
Reason why the individual is requesting services

Describe behaviors and triggers in detail

Admission Packet / Screening Information

Name of Person Completing Form

Title

Primary Diagnosis

Secondary Diagnosis

Type of Current Residence

Other Insurance

CSB/BHS

CSB/BHS Support
Coordinator Phone

Support Coordinator Name

General Individual Information

Most Prominent Means of Communication

Activities/items of interest
(primary, social, activity, tactile, token):

Dislikes

Behaviors
Describe any inappropriate behaviors and consequences. Include significant events prior to the behavior.

What goals or outcomes are you seeking from the support services?

Medical Information

Please list both prescription and over-the-counter medications

Medication

Dosage

Times

Purpose

Add another med?

History of Seizures
Yes No

Special Diet
Yes No

Allergies
Yes No

Date of Last TB Test

Results

Date of Last Physical

Completed by

Other Medical Conditions

Physician's Name

Phone

Address

City

State

Zip

Signature of Patient or Legal Guardian – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

Date

Initial Assessment

Presenting Needs Including the Individual’s:

Stated Needs

Psychiatric Needs

Support Needs

Onset and Duration of Problems

Current Medical Problems

At-Risk Behavior to Self and Others

Current and Past Substance Use or Abuse
including co-occurring mental health and substance abuse disorders

Comprehensive Assessment

Date of Onset / Duration of Problems
Developmental History Primary Diagnosis

Social / Behavioral / Developmental / Family
History and Supports

Cognitive Functioning Including Strengths
and Weaknesses

Employment / Vocational / Educational
Background

Previous Interventions / Outcomes

Financial Resources / Benefits

Health History and Current Medical Care
Needs

Allergies

Recent Physical Complaints and Medical
Conditions

Nutritional Needs

Chronic Conditions

Communicable Diseases

Restrictions on Physical Activities, if Any

Past Serious Illness, Serious Injury,
Hospitalizations

Serious Illnesses/Chronic Conditions of
the Individual’s Parents, Siblings and
Significant Others in the Same Household

Current and Past Substance Use Including
Alcohol, Prescription and Nonprescription
Medications and Illicit Drugs

Psychiatric and Substance Use Issues Including Current Mental Health or Substance Use Needs, Presence of Co-Occurring Disorders, History of Substance Use and Abuse, and Circumstances that Increase the Individual’s Risk for Mental Health or Substance Use Issues:

History of Abuse, Neglect, Sexual or
Domestic Violence, or Trauma Including
Psychological Trauma

Legal Status Including Authorized
Representative, Commitment and
Representative Payee Status

Relevant Criminal Charges or Convictions
and Probation or Parole Status

Daily Living Skills

Housing Arrangements

Ability To Access Services Including Transportation Needs

As Applicable, and In All Residential Services, Fall Risk, Communication Methods or Needs and Mobility and Adaptive Equipment Needs

Fall Risk Assessment

This form is used to assess the potential fall risk of an individual being served

Please score each line using the scale below:
4 = High Risk - individual requires close monitoring, supervision and mobility assistance due to a history of falling
3 = Moderate Risk - individual requires close monitoring, supervision and some mobility assistance due to the potential of frequent falls)
2 = Minimal Risk - individual requires occasional monitoring due to an occasional fall
1 = Low Risk - individual rarely falls and usually requires no assistance with mobility
0 = No Risk or history of falling

Points Individual has a history of recent falls

Points Individual experiences fatigue / weakness

Points Individual is experiencing agitation or delirium

Points Individual is on medications which may cause drowsiness

Points Individual has a history of hypotension

Points Individual has impaired mobility

Points Individual has a history of low or unstable blood sugar

Points Individual needs frequent toileting

Points Individual is intoxicated from alcohol or other drugs

Points Individual has an impaired mental status

Total Points

Kemetic Services employees will report all falls to the CEO / Program Director and complete an incident report when falls occur. A total score of 10 or more requires that this area be addressed as a health and safety issue.

Person Completing Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

Date

Medical History Form

Past Medical History

Do you now or have you ever had:

Other medical conditions (please list)

Family History

Father

Mother

Siblings

Children

Extended Family Psychiatric Problems Past and Present

Maternal Relatives

Paternal Relatives

Systems Review

In the past month, have you had any of the following problems?

Women's Reproductive History

Age at first period

No. of Pregnancies

No. of Miscarriages

No. of Abortions

Have you reached menopause?
Yes
No

Do you have regular periods?
Yes
No

Substance Use

Alcohol

Cannabis (Marijuana, hashish, hash oil)

Stimulants (Cocaine, crack)

Stimulants (Methamphetamine — speed, ice, crank)

Amphetamines/Other Stimulants (Ritalin, Benzedrine, Dexedrine)

Benzodiazepines/Tranquilizers (Valium, Librium, Halcion, Xanax, Diazepam, “Roofies")

Sedatives/Hypnotics/Barbiturates (Amytal, Seconal, Dalmane, Quaalude, Phenobarbital)

Heroin

Street or Illegal Methadone

Other Opiods (Tylenol #2 and #3, 282’s, 292’s, Percodan, Percocet, Opium, Morphine, Demerol, Dilaudid)

Hallucinogens (LSD, PCP, STP, MDA, DAT, mescaline, peyote, mushrooms, ecstasy (MDMA), nitrous oxide)

Inhalants (Glue, gasoline, aerosols, paint thinner, poppers, rush, locker room)

Other

Individual or Guardian Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

Date

Authorized Representative (AR) Agreement

Recommended Authorized Representative

Relationship to Individual

Authorized Representative for: (check all applicable)
Consent for Disclosure of Information
Informed Consent for Treatment
Lack of Capacity / Guardianship
Medical / Emergency Healthcare
Advance Directive / Power of Attorney
Advocate
Complaints

I am aware that the Authorized Representative is permitted by the Human Rights regulations to authorize consent for the disclosure of information, and give informed consent to treatment including medical treatment as it relates to the services provided by Kemetic Services LLC, for the above individual who currently lacks the mental capacity to make these decisions. I accept the responsibility of involving and honoring the preferences of the individual I represent in the decision making process. I understand that Kemetic Services LLC program staff will provide the opportunity to assist in this process and give any help needed to the individual I represent to ensure meaningful participation in the preparation of the services plan, discharge plan, changes to these plans and all other aspects of services received.

I further understand the following rights and responsibilities:

I will have the individual’s best interest in mind as decisions are made, taking into account the law and the individual’s religious beliefs and basic values;
I will make a good faith effort to ascertain the risks, benefits and alternatives to a proposed treatment;
I will inform the person I represent, to the extent possible of the proposed treatment;
I will attend medical treatment appointments when it is anticipated that my consent will be needed;
I may object to any part of a proposed medical treatment or discharge plan that requires informed consent;
I may give or not give authorization for disclosure of information maintained by Kemetic Services LLC regarding the individual I represent, except as required by law;
I will make decisions for the individual I represent in cases where the individual lacks the capacity to give informed consent;
I understand that the individual’s capacity for consent will be reviewed as the person’s condition warrants, or at a minimum every six months, to assess the continued need for an Authorized Representative;
I am aware that providers, in an emergency, may initiate, administer, or undertake a proposed treatment without my consent or the consent of the above individual. I will be notified immediately of the provision of treatment without my consent that occurred in an emergency.
I understand that treatment may be provided without my consent in accordance with a court order or in accordance with other provisions of law that authorize such treatment including the Health Care Decision Act (54.1-2981 et. seq.) On behalf of the individual I represent, I may request admission to or discharge from any medical treatment at any time that requires informed consent;
I will be notified if the individual I represent objects to the disclosure of specific information or a specific proposed treatment or if the individual disagrees with a decision I have made that requires informed consent. As required by the Human Rights Regulations, the Human Rights Advocate will be notified and a petition for a LHRC review may also be filed under 12 VAC 35-115-180;
At any time I determine that I am unable to continue to represent the above individual, I will provide written notice to the Program Administrator of Kemetic Services LLC.

I understand and accept the responsibility of becoming an Authorized Representative as outlined in the Human Rights Regulations, 12 VAC35-115-146.

Name of Authorized Representative

Phone

Address

City

State

Zip

I agree to the recommended appointment of the above Authorized Representative

Signature of individual – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

Date

Request for Appointment of an Authorized Representative

In accordance with the Human Rights Regulations 12 VAC 35-115-146, if an individual lacks the capacity to give informed consent, the Program Administrator may appoint an Authorized Representative.

The Program Administrator recommends appointment of an Authorized Representative for the above-named individual based upon the determination indicated below:
The Program Administrator has reviewed the individual’s record and determined that a capacity evaluation is not required. The individual is unable to communicate understanding of any action or treatment, and therefore cannot demonstrate the ability to make informed decisions regarding their medical treatment and authorization to release confidential information. There is documentation in the record to support this determination. An authorized Representative is recommended.

The Program Administrator has reviewed the attached clinical review of the individual’s capacity to give informed consent by a physician, psychologist, social worker or nurse who is not otherwise engaged in providing or offering treatment, and recommend appointment of an Authorized Representative.

The order of priority to determine the best-qualified representative was followed as outlined in the Human Rights Regulations. The individual below is recommended to represent the above person in the capacity of an Authorized Representative. The representation will be reviewed as the individual’s condition warrants, or at least every six months.

Name of Proposed AR

Relationship to Individual

dLCV Acknowledgement Form

I acknowledge and confirm that I have been informed of and provided a copy of disAbility Law Center of Virginia as listed below:

If you need information or have a complaint about:

Abuse or Neglect
Denial of Services
Discrimination based on Disability
Seclusion or Restraint
Violation of your Rights

Contact dLCV at: 1-800-552-3962
Info@dLCV.org www.dLCV.org

You have the right to contact dLCV and to do so privately.

Date

Program Rules

During the provision of Kemetic Services LLC services, individuals shall:

Refrain from the use of any abusive, vulgar, obscene, or demeaning language;
Refrain from any harassing, aggressive, threatening, or assaultive conduct toward others
Respect the property rights of others.
Do not enter anyone else’s bedroom without permission (Group Home only).

A Kemetic Services staff member has explained the foregoing rules to me, and I have read and understood them. I understand that, if a individual engages in repeated or serious violations of these rules, the client may be discharged from the Kemetic Services Program.

Signature of Individual or Guardian – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

Date

Individual Human and Home and Community Based Services (HCBS) Rights Acknowledgement Form

I acknowledge and confirm that I have been informed of and provided a copy of my Human and HCBS rights as listed below:

Human Rights

To be treated with dignity and respect
To be told about your treatment
To have a say in your treatment
To speak to others in private
To have your complaints resolved
To say what you prefer
To get help with your rights
To confidentiality
To the least restrictive setting

If you have questions or need help, see Dr. Alexander C. Moore, CEO (757) 337-3968 or contact:

Regional Advocate: Latoya Wilborne
     Eastern State Hospital
     4601 Ironbound Road
     Williamsburg, Virginia 23188
     (757) 508-2523

Home and Community Based Services (HCBS) Rights

The setting services are provided in shall:

Facilitate individual choice regarding services and supports as well as who provides the service and support.
Ensure the individual’s right to privacy, dignity, respect and freedom from coercion and restraint.
Support full access to the greater community in an integrated fashion. This includes opportunities to engage in community life, control personal resources, receive services in the community with the same level of access as individuals not receiving Medicaid HCBS.
Optimize but does not regiment individual initiative, autonomy and independence in making life choices. This includes but is not limited to daily activities, physical environment and with whom to interact.

Be physically accessible to the individuals
Support the individual’s freedom to control their own schedules and activities as well as have access to food at anytime.
Have units that are rented or occupied under a legally enforceable agreement by the individual who has at a minimum the same responsibilities and protections from eviction that tenants have under the landlord/tenant law,55.248.2 of the code of Virginia.
Support individuals to have visitors of their choosing at any time.
Support the individual’s privacy while they are sleeping or living in the unit by:
1. Units have entrance doors lockable by the individual with only appropriate staff having keys to doors.
2. Individuals sharing units have a choice of roommates.
3. Individuals have the freedom to furnish and decorate their sleeping or living units within the terms of their lease.

Modifications

Any modification of these requirements specified in items 2-5 above must be supported by a specific assessed need and justified by documentation in the person-centered service plan as follows:

Identify a specific and individualized assessed need.
Document less intrusive methods of meeting the need that has been attempted but failed to work.
Document the positive interventions and supports used prior to any modifications to the person-centered service plan.
Regular collection and review of data to measure the ongoing effectiveness of the modification.
Informed consent of the individual
Established time limits for periodic reviews to determine if the modification is still necessary or can be stopped.
Include an assurance that interventions and supports will cause no harm to the individual.

Staff Training

All Kemetic Services staff will be trained on the HCBS rights in conjunction with the mandated training required by 12VAC35-115; questions regarding these rights will be included in the objective written test administered during the initial staff in-services and annually.
Elements of the listed rights and practices for implementation are included as appropriate in both the position descriptions and the performance evaluations to emphasize the importance of the HCBS rights.

Signature of Legally Authorized Representative – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

Date

Accident / Illness Treatment Authorization

In the event of an accident or illness requiring to receive emergency medical treatment, I authorize Kemetic Services to obtain such care from his/her personal physician, or any-qualified physician available at the scene. In the event of a medical emergency, I authorize a qualified physician to performany life-saving procedures in the best interest of my health, safety, and welfare.

Signature of Individual, Legal Guardian, Authorized Representative and/or Power of Attorney – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

Date

Personal Physician

Phone

Address

City

State

Zip

I authorize Kemetic Services to provide or obtain emergency medical treatment as deemed necessary. I relieve Kemetic Services of any liability for the cost of medical care in the event of illness or accident, while I am in the care of the Kemetic Services program. The individual / receiving services and / or their Authorized Representative are responsible for any charges for services stated above. Kemetic Services will not be responsible for charges for emergency services.

Signature of Individual – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

Date

Signature of Legal Guardian / Authorized Representative / Power of Attorney – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

Date

Emergency Medical Information

Police / Fire / Rescue 911 Poison Control Center 1-800-552-6337

Whom to Contact in an Emergency

Name

Relationship

Phone

Work Phone

Address

City

State

Zip

Name

Relationship

Phone

Work Phone

Address

City

State

Zip

Advance Directive?
Yes - If yes, please provide staff a copy
No

Able to communicate verbally in an emergency?
Yes
No

Any History of Substance Abuse?
Yes
No

Current significant medical problems (including asthma, cancer history, cardiac history, hypertension, stroke, seizure, diabetes, sexually transmitted diseases, TB, HIV, hepatitis, other communicable diseases):

Other information (e.g., Sensory and ambulatory problems, walks with a cane, uses wheelchair, other medical needs, conditions affecting transportation services, etc.)

Allergies

Food

Drugs

Stings / Bites

Dietary Restrictions

Dentist Name

Phone

Address

City

State

Zip

Pharmacy Name

Phone

Address

City

State

Zip

Health Insurance Co.

Policy No.

Group No.

Signature of Person Providing the Above Information – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

Date

Relationship

Audio/Visual and Video Surveillance Policy

Complete the area for the appropriate program being admitted to.

Audio/Visual and Video Surveillance Policy for In-Home Services

I give my permission to Kemetic Services to photograph, film, and/or tape record me, with knowledge, in regards to my services received through KEMETIC SERVICES. I also give my permission for this information and material, as well as identifying information (i.e. name, age, disability, work/training background, job task) to be used for professional training, publication in the KEMETIC SERVICES newsletter and community awareness of the KEMETIC SERVICES program.

My signature below indicates that I give my permission to Kemetic Services LLC to photograph film and/or tape record me and/or to be monitored by random or fixed video surveillance equipment while participating in KEMETIC SERVICES programs.

Date
- OR -

Audio/Visual and Video Surveillance Policy for Group Home Services

I give my permission to Kemetic Services LLC to photograph, film, and/or tape record me, with knowledge, in regards to my services received through Kemetic Services. I also give my permission for this information and material, as well as identifying information (i.e. name, age, disability, work/training background, job task) to be used for professional training, publication in the Kemetic Services newsletter and community awareness of the Kemetic Services program.

In order to help insure the safety of individuals served, employees and Kemetic Services property, in Group Home settings only, Kemetic Services reserves the right to monitor its facilities in the common living areas such (as living room, hallways, dining room, laundry room, yards, front and back door) and/or vehicles via video cameras. Bedrooms and bathrooms will never be videotaped.

My signature below indicates that I give my permission to Kemetic Services LLC to photograph film and/or tape record me and/or to be monitored by random or fixed video surveillance equipment while in the common living areas of the group home and/or vehicles during the time I reside at the group home located at 2136 Jeffrey Drive, Norfolk, VA 23518.

Date

Consent to Exchange Information
REACH

I understand that different agencies provide services and benefits. Each agency must have specific information in order to provide services and benefits. By signing this form, I am allowing agencies to exchange certain information so it will be easier for them to work together effectively to provide or coordinate these services or benefits.

I (full name of consenting person or persons) am signing this form for

Individual Name

Phone

Birthdate

SSN

Address

City

State

Zip

I want the following confidential information about the individual (except drug or alcohol abuse diagnosis or treatment information to be exchanged):

Assessment
Information
Yes
No

Financial
Information
Yes
No

Benefits - Services Needed,
Planned, and/or Received
Yes
No

Medical
Diagnosis
Yes
No

Mental Health
Diagnosis
Yes
No

Medical
Records
Yes
No

Psychological
Records
Yes
No

Educational
Records
Yes
No

Psychiatric
Records
Yes
No

Criminal Justice
Records
Yes
No

Employment
Records
Yes
No

Other Information You Want

Name of Agency
     REACH - Regional, Education, Assessment, Crisis Services, Habilitation

Agency Address
     7025 Harbour View Blvd., Suite 119
     Suffolk, Virginia 23435

Phone
     1-888-255-2989

I want this information to be exchanged ONLY for the following purpose(s):
Service Coordination and Treatment Planning
Eligibility / Admission Determination
Other

I want information to be shared: (check all that apply)
Written Information
In Meetings or By Phone
Computerized Data

I want to share additional information received after this consent is signed
Yes
No

This consent is good until (one year) from date of signature

I can withdraw this consent at any time by telling the referring agency. This will stop the listed agency from sharing information after they know my consent has been withdrawn.
I have the right to know what information about me has been shared, and why, when, and with whom it was shared. If I ask, the agency and / or person receiving confidential documents will show me this information.
If I do not sign this form, information will not be shared and I will have to contact each agency individually to give them information about me that they request.

Date

Witness - if required

Consent to Exchange Information
Kemetic Services, LLC

I (full name of consenting person or persons) am signing this form for

Individual Name

Phone

Birthdate

SSN

Address

City

State

Zip

I want the following confidential information about the individual (except drug or alcohol abuse diagnosis or treatment information to be exchanged):

Assessment
Information
Yes
No

Financial
Information
Yes
No

Benefits - Services Needed,
Planned, and/or Received
Yes
No

Medical
Diagnosis
Yes
No

Mental Health
Diagnosis
Yes
No

Medical
Records
Yes
No

Psychological
Records
Yes
No

Educational
Records
Yes
No

Psychiatric
Records
Yes
No

Criminal Justice
Records
Yes
No

Employment
Records
Yes
No

Other Information You Want

Name of Agency
     Kemetic Services, LLC

Agency Address
     2428 Almeda Ave., Suite 170
     Norfolk, Virginia 23513

Phone
     757-337-3968

I want this information to be exchanged ONLY for the following purpose(s):
Service Coordination and Treatment Planning
Eligibility / Admission Determination
Other

I want information to be shared: (check all that apply)
Written Information
In Meetings or By Phone
Computerized Data

I want to share additional information received after this consent is signed
Yes
No

This consent is good until (one year) from date of signature

I can withdraw this consent at any time by telling the referring agency. This will stop the listed agency from sharing information after they know my consent has been withdrawn.
I have the right to know what information about me has been shared, and why, when, and with whom it was shared. If I ask, the agency and / or person receiving confidential documents will show me this information.
If I do not sign this form, information will not be shared and I will have to contact each agency individually to give them information about me that they request.

Date

Witness - if required

Consent to Exchange Information
Community Services Board

I (full name of consenting person or persons) am signing this form for

Individual Name

Phone

Birthdate

SSN

Address

City

State

Zip

I want the following confidential information about the individual (except drug or alcohol abuse diagnosis or treatment information to be exchanged):

Assessment
Information
Yes
No

Financial
Information
Yes
No

Benefits - Services Needed,
Planned, and/or Received
Yes
No

Medical
Diagnosis
Yes
No

Mental Health
Diagnosis
Yes
No

Medical
Records
Yes
No

Psychological
Records
Yes
No

Educational
Records
Yes
No

Psychiatric
Records
Yes
No

Criminal Justice
Records
Yes
No

Employment
Records
Yes
No

Other Information You Want

Name of Agency
Community Services Board

Agency Address

City

State

Zip

Phone

I want this information to be exchanged ONLY for the following purpose(s):
Service Coordination and Treatment Planning
Eligibility / Admission Determination
Other

I want information to be shared: (check all that apply)
Written Information
In Meetings or By Phone
Computerized Data

I want to share additional information received after this consent is signed
Yes
No

This consent is good until (one year) from date of signature

I can withdraw this consent at any time by telling the referring agency. This will stop the listed agency from sharing information after they know my consent has been withdrawn.
I have the right to know what information about me has been shared, and why, when, and with whom it was shared. If I ask, the agency and / or person receiving confidential documents will show me this information.
If I do not sign this form, information will not be shared and I will have to contact each agency individually to give them information about me that they request.

Date

Witness - if required

Consent to Exchange Information
Primary Care Physician

I (full name of consenting person or persons) am signing this form for

Individual Name

Phone

Birthdate

SSN

Address

City

State

Zip

I want the following confidential information about the individual (except drug or alcohol abuse diagnosis or treatment information to be exchanged):

Assessment
Information
Yes
No

Financial
Information
Yes
No

Benefits - Services Needed,
Planned, and/or Received
Yes
No

Medical
Diagnosis
Yes
No

Mental Health
Diagnosis
Yes
No

Medical
Records
Yes
No

Psychological
Records
Yes
No

Educational
Records
Yes
No

Psychiatric
Records
Yes
No

Criminal Justice
Records
Yes
No

Employment
Records
Yes
No

Other Information You Want

Name of Physician

Phone

Physician Address

City

State

Zip

I want this information to be exchanged ONLY for the following purpose(s):
Service Coordination and Treatment Planning
Eligibility / Admission Determination
Other

I want information to be shared: (check all that apply)
Written Information
In Meetings or By Phone
Computerized Data

I want to share additional information received after this consent is signed
Yes
No

This consent is good until (one year) from date of signature

I can withdraw this consent at any time by telling the referring agency. This will stop the listed agency from sharing information after they know my consent has been withdrawn.
I have the right to know what information about me has been shared, and why, when, and with whom it was shared. If I ask, the agency and / or person receiving confidential documents will show me this information.
If I do not sign this form, information will not be shared and I will have to contact each agency individually to give them information about me that they request.

Date

Witness - if required

Consent to Exchange Information
Department of Behavioral Health and Developmental Services (DBHDS)

I (full name of consenting person or persons) am signing this form for

Individual Name

Phone

Birthdate

SSN

Address

City

State

Zip

I want the following confidential information about the individual (except drug or alcohol abuse diagnosis or treatment information to be exchanged):

Assessment
Information
Yes
No

Financial
Information
Yes
No

Benefits - Services Needed,
Planned, and/or Received
Yes
No

Medical
Diagnosis
Yes
No

Mental Health
Diagnosis
Yes
No

Medical
Records
Yes
No

Psychological
Records
Yes
No

Educational
Records
Yes
No

Psychiatric
Records
Yes
No

Criminal Justice
Records
Yes
No

Employment
Records
Yes
No

Other Information You Want

Name of Agency
     Department of Behavioral Health and Developmental Services (DBHDS)

Agency Address
     1220 Bank St.
     Richmond, Virginia 23219

Phone
     804-786-3921

I want this information to be exchanged ONLY for the following purpose(s):
Service Coordination and Treatment Planning
Eligibility / Admission Determination
Other

I want information to be shared: (check all that apply)
Written Information
In Meetings or By Phone
Computerized Data

I want to share additional information received after this consent is signed
Yes
No

This consent is good until (one year) from date of signature

I can withdraw this consent at any time by telling the referring agency. This will stop the listed agency from sharing information after they know my consent has been withdrawn.
I have the right to know what information about me has been shared, and why, when, and with whom it was shared. If I ask, the agency and / or person receiving confidential documents will show me this information.
If I do not sign this form, information will not be shared and I will have to contact each agency individually to give them information about me that they request.

Date

Witness - if required

Consent to Exchange Information
Virginia Department of Medical Assistant Services (DMAS)

I (full name of consenting person or persons) am signing this form for

Individual Name

Phone

Birthdate

SSN

Address

City

State

Zip

I want the following confidential information about the individual (except drug or alcohol abuse diagnosis or treatment information to be exchanged):

Assessment
Information
Yes
No

Financial
Information
Yes
No

Benefits - Services Needed,
Planned, and/or Received
Yes
No

Medical
Diagnosis
Yes
No

Mental Health
Diagnosis
Yes
No

Medical
Records
Yes
No

Psychological
Records
Yes
No

Educational
Records
Yes
No

Psychiatric
Records
Yes
No

Criminal Justice
Records
Yes
No

Employment
Records
Yes
No

Other Information You Want

Name of Agency
     Virginia Department of Medical Assistant Services (DMAS)

Agency Address
     600 E. Broad Street
     Richmond, Virginia 23219

Phone
     804-756-7933

I want this information to be exchanged ONLY for the following purpose(s):
Service Coordination and Treatment Planning
Eligibility / Admission Determination
Other

I want information to be shared: (check all that apply)
Written Information
In Meetings or By Phone
Computerized Data

I want to share additional information received after this consent is signed
Yes
No

This consent is good until (one year) from date of signature

I can withdraw this consent at any time by telling the referring agency. This will stop the listed agency from sharing information after they know my consent has been withdrawn.
I have the right to know what information about me has been shared, and why, when, and with whom it was shared. If I ask, the agency and / or person receiving confidential documents will show me this information.
If I do not sign this form, information will not be shared and I will have to contact each agency individually to give them information about me that they request.

Date

Witness - if required

Consent to Exchange Information
Department of Human Services (DHS)

I (full name of consenting person or persons) am signing this form for

Individual Name

Phone

Birthdate

SSN

Address

City

State

Zip

I want the following confidential information about the individual (except drug or alcohol abuse diagnosis or treatment information to be exchanged):

Assessment
Information
Yes
No

Financial
Information
Yes
No

Benefits - Services Needed,
Planned, and/or Received
Yes
No

Medical
Diagnosis
Yes
No

Mental Health
Diagnosis
Yes
No

Medical
Records
Yes
No

Psychological
Records
Yes
No

Educational
Records
Yes
No

Psychiatric
Records
Yes
No

Criminal Justice
Records
Yes
No

Employment
Records
Yes
No

Other Information You Want

Name of Agency

Phone

Address

City

State

Zip

I want this information to be exchanged ONLY for the following purpose(s):
Service Coordination and Treatment Planning
Eligibility / Admission Determination
Other

I want information to be shared: (check all that apply)
Written Information
In Meetings or By Phone
Computerized Data

I want to share additional information received after this consent is signed
Yes
No

This consent is good until (one year) from date of signature

I can withdraw this consent at any time by telling the referring agency. This will stop the listed agency from sharing information after they know my consent has been withdrawn.
I have the right to know what information about me has been shared, and why, when, and with whom it was shared. If I ask, the agency and / or person receiving confidential documents will show me this information.
If I do not sign this form, information will not be shared and I will have to contact each agency individually to give them information about me that they request.

Date

Witness - if required

Individual Orientation Checklist

Mission of Kemetic Services, LLC

Service Confidentiality Practices and Protections for Individuals Receiving Services

Human Rights Policies and Protections and Instructions on How to Report Violations

Opportunities for Participation in Services and Discharge Planning

Fire Safety and Emergency Preparedness Procedures, if Applicable

Kemetic Services, LLC Grievance Procedure

Services Guidelines Including Criteria for Admission to and Discharge or Transfer from Services

Hours and Days of Operation

Video Camera Survelliance on Premises

Availability of After-Hours Service

Any Charges and Fees Due from the Individual

Documentation that Orientation Has Been Provided to Individual and Legal Guardian / Authorized Representative Kemetic Services, LLC, if Applicable

Procedure for Notification of New Polices

Date

Plan for Supports

The state of Virginia requires all ISP's and support instructions to be signed.
A final copy of the plan and support instructions will be sent to you once it has been completed.

Nothing should be completed on this section except your signature and date at the bottom.

Outcomes and Activities

Desired Outcome

Key steps and services to get there

Activity Statement

I no longer want/need supports when

What to record

Skill Building
Yes
No

If yes, describe specific skill

How Often

By When

Signature below confirms that the types, reasons/purposes, explanation, risk, and benefits regarding alternative services that might be advantageous for the person this ISP has been created for have been reviewed.

Date

Signature of Substitute Decision Maker – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

Date

LuxSci helps ensure HIPAA-compliance for email and web services.

Application / Preliminary Assessment

Skills and Behaviors Checklist

Individual Screening Documentation Sheet

Admission Packet / Screening Information

Initial Assessment

Comprehensive Assessment

Fall Risk Assessment

Medical History Form

Authorized Representative (AR) Agreement

dLCV Acknowledgement Form

Program Rules

Individual Human and Home and Community Based Services (HCBS) Rights Acknowledgement Form

Accident / Illness Treatment Authorization

Emergency Medical Information

Audio/Visual and Video Surveillance Policy

Consent to Exchange InformationREACH

Consent to Exchange InformationKemetic Services, LLC

Consent to Exchange InformationCommunity Services Board

Consent to Exchange InformationPrimary Care Physician

Consent to Exchange InformationDepartment of Behavioral Health and Developmental Services (DBHDS)

Consent to Exchange InformationVirginia Department of Medical Assistant Services (DMAS)

Consent to Exchange InformationDepartment of Human Services (DHS)

Individual Orientation Checklist

Plan for Supports

Consent to Exchange Information
REACH

Consent to Exchange Information
Kemetic Services, LLC

Consent to Exchange Information
Community Services Board

Consent to Exchange Information
Primary Care Physician

Consent to Exchange Information
Department of Behavioral Health and Developmental Services (DBHDS)

Consent to Exchange Information
Virginia Department of Medical Assistant Services (DMAS)

Consent to Exchange Information
Department of Human Services (DHS)