Intake forms - Plainfield Youth Assistance Program

INTAKE FORM
AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION FOR COLLABORATIVE AGENCIES
RELEASE OF CONFIDENTIAL INFORMATION FOR PCSC

Name of Youth*
First
Date of Birth
Date Format: MM slash DD slash YYYY
Address
Street Address
City
Zip
Parent/Legal Guardian:
First
Address
Street Address
City
Zip
I HEREBY AUTHORIZE The Plainfield Youth Assistance Program, Inc. to Exchange information, when needed, with the collaborative agencies and other professionals associated with the PYAP, Inc..
The purpose of disclosure is for coordination of care, programming, and potential data after an event/activity.

This consent is valid for until: TERMINATION/Completion of Services.

I understand that this information may include information relating to:

a. Mental, emotional, or behavioral health;
b. Medical care;
c. Attendance, behaviors;
d. COVID-19.
e. Other

I understand that I may revoke this authorization at any time by notifying our Advocate or the Director of the Plainfield Youth Assistance Program, Inc. in writing of my intent to revoke this authorization. If I do notify the Plainfield Youth Assistance Program, Inc. in writing, of my intent to revoke this authorization, such revocation will not have any effect on
any actions taken by the Plainfield Youth Assistance Program, Inc. before the revocation. Written Notification must be
delivered to the Plainfield Youth Assistance Program Advocate or Director.

I understand that the Plainfield Youth Assistance Program will give me a copy of this authorization form after I sign it.

I understand that my records will be professionally and ethically maintained by PYAP, Inc. as provided by the statutes of
the State of Indiana, and the Codes of Ethics and Professional Standards of our profession. Please be aware that once
your records are released, this provider can no longer insure their confidentiality.

Name of Youth*
First
Date of Birth
Date Format: MM slash DD slash YYYY
Address
Street Address
City
Zip
Parent/Legal Guardian:
First
Address
Street Address
City
Zip
I HEREBY AUTHORIZE The Plainfield Youth Assistance Program, Inc. to Exchange information with Plainfield Community School Corporation.
The purpose of disclosure is for:
- Coordination of Care
- Consultation with School
This consent is valid until: TERMINATION/Completion of Services.
I understand that this information may include information relating to:

a. Acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV) infection;
b. Substance abuse;
c. Mental, emotional, or behavioral health;
d. Medical care;
e. COVID-19.
f. Other

I understand that I may revoke this authorization at any time by notifying our Advocate or the Director of the Plainfield
Youth Assistance Program, Inc. in writing of my intent to revoke this authorization. If I do notify the Plainfield Youth
Assistance Program, Inc. in writing, of my intent to revoke this authorization, such revocation will not have any effect on
any actions taken by the Plainfield Youth Assistance Program, Inc. before the revocation. Written Notification must be
delivered to the Plainfield Youth Assistance Program Advocate or Director.

I understand that the Plainfield Youth Assistance Program will give me a copy of this authorization form after I sign it. I
understand that my records will be professionally and ethically maintained by PYAP, Inc. as provided by the statutes of
the State of Indiana, and the Codes of Ethics and Professional Standards of our profession. Please be aware that once
your records are released, this provider can no longer insure their confidentiality

First and Last Name	Date of Birth	Age	With whom does child reside?

Name of Child	Medication	Mg & #Times/day	Prescribing Physician/Psychiatrist

Name of Child	Name if School	Home Teacher	Grade	Counselor	Additional Special Need

Name of Child	Medical History

Name of Child	Current Diagnosis

Name of Child	IEP [Yes / No]

Name of Child	504 [Yes / No]