Chosen Care Application
This form will take approximately less than 10 minutes to complete.

Applicant information

  • Applicant must personally complete this application. Application cannot be filled out by a third party or by the referring party.
 

Parents/Caregivers

  • Please list name of all PARENTS/CAREGIVERS in the home (include yourself).
 

Other Adults

 

Emergency Contact

  • Please list the name, relationship, and phone number of an EMERGENCY CONTACT.
 

Additional Information

 

Children’s Information

  • Please list ALL CHILDREN.
 

Authorization

  • Application Consent
  • By submitting this form, I agree that: I have read the information at the link above and wish to partake in Chosen’s Services with my assigned Care Manager.
  • I understand that I have no financial obligation to Chosen for the initial two complimentary sessions. I understand that there is no obligation to continue services past these two sessions. I understand that my information will be kept on file during and after my services are complete.
  • I acknowledge that I have read and understand the above Electronic Records Disclosure and have been given the opportunity to ask questions about it.
  • By signing this informed consent for services form, you agree that you have reviewed this informed consent for services form, and acknowledge you have read and understood all the terms and information contained in it and that ample opportunity has been offered to you to ask questions and seek clarification of anything unclear to you. Furthermore, you agree to abide by all policies outlined herein. I understand the Research Consent explained above and consent to allowing the assessment results to be used in Chosen’s Outcomes Research Project.
  • Client Consent to the Use of Telehealth- I have read and understand the information provided above regarding telehealth, have discussed it with my Care Manager, and all my questions have been answered to my satisfaction. I have read this document carefully and understand the risks and benefits related to the use of telehealth services and have had my questions regarding the procedure explained. I hereby give my informed consent to participate in the use of telehealth services for treatment under the terms described herein. By my signature below, I hereby state that I have read, understood, and agree to the terms of this document.
  • Applicant must personally sign this application. Application cannot be signed on behalf of potential client either by a third party or by the referring party.
 

Verification