Staff & Board
Resource Assistance Application
Resource Assistance Application
Please list the name, birthdate, ethnicity, & occupation for parents/caregivers in the home:
Provide the name, birthdate, ethnicity, & relationship of all other persons living in the home:
Apt, Suite, Bldg. (optional)
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Bosnia and Herzegovina
Central African Republic
East Timor (Timor Timur)
Papua New Guinea
Saint Kitts and Nevis
Sao Tome and Principe
Trinidad and Tobago
United Arab Emirates
United States of America
Household income range
Less than $50,000
More than $150,000
If you have a foster placement, what county has jurisdiction over your child’s case?
If you have a foster placement, what dates did your children enter your home?
If you adopted internationally, from what country did you adopt?
What is the name of the foster care or adoption agencies that you used?
What resources do you need Chosen’s assistance in securing?
Other (please explain:
Chosen Care, Inc. Client Release of Liability
The legal entity of Chosen Care, Inc, including all staff members, contract employees, and volunteer mentors, will be referred to as “Chosen” throughout this document.
1.) Confidentiality: The Health Insurance Portability and Accountability Act (HIPPA) provides patient protections related to the electronic transmission of data, the keeping and use of patient records, and storage and access to health care records. HIPPAA applies to all heath care providers, including mental health care, and providers and health care agencies throughout the country are now required to provide patients a notification of their privacy rights as it relates to their health care records. An explanation of those rights is attached to this document. Communications between client and Chosen staff and/or Chosen mentors are confidential and will not be revealed unless required by law such as in situations of:
• child abuse, elder abuse, or threats of physical harm to self or others
• for clinical supervision purposes
• if subpoenaed by a court of law
• if a guardian ad litem (GAL) is appointed in a custody case involving parents of adolescent clients Chosen staff has seen for counseling services and she/he is ordered by the court to have access to records, I am required to provide that information as it is court ordered.
• the Patriot Act of 2001 requires me in certain circumstances, to provide federal law agents with records, papers and documents upon request and prohibits me from disclosing to my client that the FBI sought or obtained the items under the Act.
2.) Release of Information: Chosen will only share information about parent coaching sessions with other professionals or agencies if a Release-of-information form is completed and signed.
3.) One entity: In working with couples and families, Chosen views the couple and family as an entity as our client.
4.) Cancellation of Appointments: If you must cancel your appointment for any reason, please phone your parent educator at least 24 business hours in advance of your scheduled appointment. If you should arrive late for an appointment, the appointment will begin shortly after your arrival and end at the normal time.
5.) Results: You have the right to choose to participate in the Trauma-informed Action Plan created by Chosen for your family. Through trauma-informed parental techniques and resources, Chosen will offer you ways in which you can reach the goals and objectives for your family. Chosen’s services will be practiced in a professional manner. Please know that it is impossible to guarantee any specific results regarding these goals.
6.) Emergency Procedures: Chosen is not staffed with a receptionist or paging system; therefore, we are not equipped to handle emergency situations. In the case of an emergency, we recommend you contact either a hospital emergency room or the police depending on the situation.
7.) Divorce/Custody Disputes: If you are ever become involved in a divorce or custody dispute, Chosen is not able to provide evaluations or expert testimony in court. By signing this informed consent document, you are acknowledging your understanding and agreement.
8.) Release of Liability: Release of Liability: While Chosen may recommend what we understand to be vetted, best-in-class trauma-informed professionals and resources, and might provide volunteer mentors, Chosen does not provide any professional advice, including, but not limited to, legal advice, medical advice, or financial advice. In consideration of the benefits you derive from Chosen and its services, you hereby agree to release, discharge, and forever hold harmless Chosen (and its agents, successors or assigns) from any and all claims, counterclaims, causes of action, damages, or suits, known or unknown, fixed or contingent, liquidated or unliquidated, arising from or related to your receipt of services from Chosen or any outside professional recommended by Chosen. This release is binding upon, the you and your attorneys, agents, partners, heirs, devisees, personal representatives, legal representatives, successors and/or assignees. By signing this informed consent document, you are acknowledging your understanding of this release and your agreement to it.
Signing below indicates that I fully understand what I have just read and voluntarily request parent education and mentoring services at Chosen and I agree to these terms and conditions.
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Patient Notification of Privacy Rights
THIS FORM DESCRIBES THE CONFIDENTIALITY OF YOUR MEDICAL RECORDS, HOW THE INFORMATION IS USED, YOUR RIGHTS, AND HOW YOU MAY OBTAIN THIS INFORMATION. (EFFECTIVE 4-14-03)
LEGAL DUTIES: State and Federal laws require that we keep your medical records private. Such laws require that we provide you with this notice informing you of our privacy of information policies, your rights, and our duties. We are required to abide these policies until replaced or revised. We have the right to revise our privacy policies for all medical records, including records kept before policy changes were made. Any changes in this notice will be made available upon request before changes take place. The contents of material disclosed to us in an evaluation, intake, or counseling session are covered by the law as private information. We respect the privacy of the information you provide us and we abide by ethical and legal requirements of confidentiality and privacy of records.
USE OF INFORMATION: Information about you may be used by the personnel associated with this organization for diagnosis, treatment planning, treatment, and continuity of care. We may disclose it to health care providers who provide you with treatment, such as doctors, nurses, mental health professionals, and mental health students and mental health professionals or business associates affiliated with this clinic such as billing, quality enhancement, training, audits, and accreditation. Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client’s legal guardian or personal representative. It is the policy of this organization not to release any information about a client without a signed release of information except in certain emergency situations or exceptions in which client information can be disclosed to others without written consent. Some of these situations are noted below, and there may be other provisions provided by legal requirements.
DUTY TO WARN AND PROTECT: When a client discloses intentions or a plan to harm another person or persons, the health care professional is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client.
PUBLIC SAFETY: Health records may be released for the public interest and safety for public health activities, judicial and administrative proceedings, law enforcement purposes, serious threats to public safety, essential government functions, military, and when complying with worker’s compensation laws.
ABUSE: If a client states or suggests that he or she is abusing a child or vulnerable adult, or has recently abused a child or vulnerable adult, or a child (or vulnerable adult) is in danger of abuse, the health care professional is required to report this information to the appropriate social service and/or legal authorities. If a client is the victim of abuse, neglect, violence, or a crime victim, and their safety appears to be at risk, we may share this information with law enforcement officials to help prevent future occurrences and capture the perpetrator.
PRENATAL EXPOSURE TO CONTROLLED SUBSTANCES: Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful.
IN THE EVENT OF A CLIENT’S DEATH: In the event of a client’s death, the spouse or parents of a deceased client has a right to access his/her child’s or spouse’s records.
PROFESSIONAL MISCONDUCT: Professional misconduct by a health care professional must be reported by other health care professionals. In cases in which a professional or legal disciplinary meeting is being held regarding the health care professional’s actions, related records may be released in order to substantiate disciplinary concerns.
JUDICIAL OR ADMINISTRATIVE PROCEEDINGS: Health care professionals are required to release records of clients when a court order has been placed. MINORS/GUARDIANSHIP: Parents or legal guardians of non-emancipated minor clients have the right to access the client’s records.
OTHER PROVISIONS: When payment for services are the responsibility of the client, or a person who has agreed to providing payment, and payment has not been made in a timely manner, collection agencies may be utilized in collecting unpaid debts. The specific content of the services (e.g., diagnosis, treatment plan, progress notes, testing) is not disclosed. If a debt remains unpaid it may be reported to credit agencies, and the client’s credit report may state the amount owed, the time-frame, and the name of the clinic or collection source. Insurance companies, managed care, and other third-party payers are given information that they request regarding services to the client. Information which may be requested includes type of services, dates/times of services, diagnosis, treatment plan, description of impairment, progress of therapy, and summaries. Information about clients may be disclosed in consultations with other professionals in order to provide the best possible treatment. In such cases the name of the client, or any identifying information, is not disclosed. Clinical information about the client is discussed. Some progress notes and reports are dictated/typed within the clinic or by outside sources specializing in (and held accountable for) such procedures.
In the event in which the clinic or mental health professional must telephone the client for purposes such as appointment cancellations or reminders, or to give/receive other information, efforts are made to preserve confidentiality. Please notify us in writing where we may reach you by phone and how you would like us to identify ourselves. For example, you might request that when we phone you at home or work, we do not say the name of the clinic or the nature of the call, but rather the mental health professional’s first name only. If this information is not provided to us (below), we will adhere to the following procedure when making phone calls: first we will ask to speak to the client (or guardian) without identifying the name of the clinic. If the person answering the phone asks for more identifying information we will say that it is a personal call. We will not identify the clinic (to protect confidentiality). If we reach an answering machine or voice mail, we will follow the same guidelines.
YOUR RIGHTS: You have the right to request to review or receive your medical files. The procedures for obtaining a copy of your medical information is as follows. You may request a copy of your records in writing with an original (not photocopied) signature. If your request is denied, you will receive a written explanation of the denial. Records for non-emancipated minors must be requested by their custodial parents or legal guardians. The charge for this service is $1 per page, plus postage. You have the right to cancel a release of information by providing us a written notice. If you desire to have your information sent to a location different than our address on file, you must provide this information in writing. You have the right to restrict which information might be disclosed to others. However, if we do not agree with these restrictions, we are not bound to abide by them. You have the right to request that information about you be communicated by other means or to another location. This request must be made to us in writing. Your have the right to disagree with the medical records in our files. You may request that this information be changed. Although we might deny changing the record, you have the right to make a statement of disagreement, which will be placed in your file. You have the right to know what information in your record has been provided to whom. Request this in writing. If you desire a written copy of this notice you may obtain it by requesting it from the Clinic Director at this location.
COMPLAINTS: If you have any complaints or questions regarding these procedures, please contact the clinic. We will get back to you in a timely manner. You may also submit a complaint to the U.S. Dept. of Health and Human Services and/or the Georgia Board of Counseling. If you file a complaint we will not retaliate in any way.
The Health Insurance Portability and Accountability Act (HIPAA) has created new patient protections surrounding the use of protected health information. Commonly referred to as the “medical records privacy law,” HIPAA provides patient protections related to the electronic transmission of data (“the transaction rules”), the keeping and use of patient records (“privacy rules”), and storage and access to health care records (“security rules”). HIPAA applies to all heath care providers, including mental health care, and providers and health care agencies thought the country are now required to provide patients a notification of their privacy rights as it relates to their health care records. You may have already received similar notices such as this one from your other health care providers.
As you might expect, the HIPAA law and regulations are extremely detailed and difficult to grasp if you don’t have formal legal training. This Patient Notification of Privacy Rights is our attempt to inform you of your rights in a simple yet comprehensive fashion. Please read this document, as it is important you know what patient protections HIPAA affords all of us. In mental health care, confidentiality and privacy are central to the success of therapeutic relationship, and as such, you will find we make every effort to do all we can to protect the privacy of your mental health records. If you have any questions about any of the matters discussed in this document, please do not hesitate to ask for further clarification.
By law, Chosen is required to secure your signature indicating you have received a copy of the Patient Notification of Privacy Rights document.
Chosen HIPAA Compliance Officer: Savannah Wehling
I have received a copy of Chosen’s Patient Notification of Privacy Rights document, which provides a detailed description of the potential uses and disclosures of my protected health information, as well as my rights on these matters. I understand that I have the right to review this document and I may at any time, not or later, as any questions about or seek clarification of the matters discussed in this document.
Signing below indicates only that I have received a copy of the Patient Notification of Privacy Rights document.
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Staff & Board