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					                                                                  Division of Mental Health, Developmental
MD/DD/SAS Contract Agency                                         Disabilities, Substance Abuse Services

CLIENT NAME                                               REC. #____________

I. Consent for Placement Services:

Placement: YOUTH QUEST RESIDENTIAL TREATMENT FACILITY                               Date:

I, hereby, give my consent for the provision of services by the Youth Quest Residential Treatment Program for

                                      .
       (Name of client)

I,                                        release the Youth Quest Facility and all of its employees from liability

on account of injury or damage to                                           while in residential care.
                                               (Name of client)

I understand and agree not to hold Youth Quest responsible for in any injury to my child occurring during residential care. Further, I
understand that should my child choose to leave the premises while in the care of residential service without appropriate permission,
Youth Quest will not be held liable for any injury to or damage done by my child while he/she is off the premises.

This consent is signed on a voluntary basis. I understand that I may revoke this consent at any time. I will not hold Youth Quest or its
employees responsible for injury to my child while he or she is in their care. My signature certifies my understanding and agreement
with all of the above consents.




Parent or Guardian                                       Date


Witness                                                  Date
                                                          Division of Mental Health, Developmental
MD/DD/SAS Contract Agency                                 Disabilities, Substance Abuse Services

                                    YOUTH QUEST DAMAGE RELEASE CONSENT

Date:_____/_____/_____                      Client Record #_____________
Client name: _____________________________________
Parent/Legal Guardian name: __________________________________
    1. RISK FACTORS. The undersigned understands and acknowledges that the activities of Youth Quest may involve
       some risk. Some activities that involve risk are swimming, weight lifting, outdoor sports, beach activities, etc.
       Risk might result from the activity itself, the acts of others or the unavailability of emergency care; RISK OF
       PROPERTY DAMAGE, BODILY INJURY, and POSSIBLY DEATH.
    2. ASSUMPTION OF RISK. The undersigned ASSUMES ALL RISKS WHICH ARE FORESEEABLE AND
       INVOLVED WITH OR ARISING FROM DAILY ACTIVITIES, including without limitation those risks
       described in Section 1 above.
    3. RELEASE. The undersigned RELEASES Youth Quest and all of their officers, board members, and employees
       and agrees NOT TO SUE them on account of or in connection with any claims, causes of action, injuries, damages,
       cost or expenses (referred to below as “CLAIMS”) arising out of any activity, teaching, or daily activities including
       those based on the risks described in Section 1, whether or not caused by the negligence or other fault of the
       RELEASED PARTIES.
    4. WAIVER. The undersigned waives the protection provided by any statue or law in any jurisdiction including
       North Carolina Code who purpose, substances and/or effect is to provide them a general release shall not extend to
       claims, material or otherwise which the persons giving the release does not know or suspect to exist at the time of
       the executing the release. This means, in apart, that the undersigned is releasing unknown future claims.
    5. INDEMNIFY AND DEFEND. The undersigned agrees to INDEMNIFY AND DEFEND the RELEASED
       PARTIES against, and hold them harmless from, any and all CLAIMS, including attorney fees, which in any way
       arise from any activity which is the subject of this agreement and which include but are not limited to those risks
       described in Section 1 including any liability arising from the act or negligent act of the RELEASED PARTIES,
       the below named minor or anyone else.
    6. PAY. The undersigned agrees to pay for ANY AND ALL DAMAGES to any property of Youth Quest, the
       released parties caused by the undersigned, the minor, whether negligently, willfully, or otherwise. Incidents
       involving damage in excess of $1000 may be claimed on Youth Quest insurance. The legal guardian agrees to pay
       up to $1000 per claim/per incident for damages caused by the client, the minor, whether negligently, willfully, or
       otherwise to The Quest property or vehicles and will make payment within 30 days of incident.
    7. LEGAL FEES. In the event of any controversy, claim or dispute between the parties arising out of or relating to
       this agreement or the breach hereof or the activity, the prevailing party shall be entitled to recover from the losing
       party reasonable expenses, attorney fees, and costs.
    8. REPRESENTATIVES. The undersigned enters into this agreement for himself/herself, the minor who is or will be
       served by Youth Quest, heirs, assigns, and legal representatives.
    9. ACKNOWLEDGEMENT. The undersigned has read and understands this agreement and realizes it relates to
       releasing valuable legal rights and does so freely and voluntarily.

TO BE COMPLETED BY PARENT, OR LEGAL GUARDIAN
I am the parent and/or legal guardian of the above named minor. I have read and understand the agreement and realize the
agreement involves releasing valuable legal rights of the minor and myself. I agree to be bound by all of the terms of the
agreement. I also give my consent to the participation in the activity of the minor.

                                      Date:_____/_____/_____
Parent or Legal Guardian (BEFORE ANY VIDEO RECORDINGS)


                                          Date:_____/_____/_____
Witness
                                                                Division of Mental Health, Developmental
MD/DD/SAS Contract Agency                                       Disabilities, Substance Abuse Services

                                      YOUTH QUEST CLIENT CONSENT TO
                           VIDEO RECORDING FOR TEACHING AND ASSESSMENT PURPOSES

Date:_____/_____/_____                              Client Record #_____________
Client name: _____________________________________
Parent/Legal Guardian name: __________________________________
    o Youth Quest utilizes the Teaching Family Model of treatment for the youth who are served in our residential treatment homes.
          This model provides many opportunities for our staff, called Practitioners or Family Teacher Practitioners, to utilize the
         Teaching Family Model of Care. This model maintains strict and rigorous standards to insure that all staff are teaching and
         counseling the youth and families served with the highest program model fidelity.
    o The couple and staff who work with the youth in the home are occasionally reviewed by a Teaching Family Model consultant
         who assists the staff in using the model correctly.
    o It is our hope that we will be able to make recordings as needed for regular teaching and assessment of staff. The videos are
         for use in helping the Family Teacher Practitioners prepare for an annual Teaching Family Model Certification as part of their
         training.
    o Video footage will only be taken in common areas of the home which include the great room, the kitchen, the sunroom, the
         living room, the office, the outside, the deck, etc. All video recordings will be carried out according to HIPAA regulations.
    o Only people directly involved in the teaching interactions will see the video. It will only be used to assess the Family Teacher
         Practitioners who provide care to your youth, and possibly for research (Duke University), learning, and teaching purposes.
         The DVD/VHS will be securely stored off site and is subject to the same degree of confidentiality as your medical records.
         The DVD/VHS will be erased as soon as practicable and in any event within three years unless an archive consent is obtained.
    o The security and confidentiality of the video recording are the responsibility of the supervising consultant, the family teacher
         practitioners, or other assessment authority to whose care it is entrusted. If the DVD/VHS is to leave the secure site, it will be
         sent by registered post, by personal messenger, or some other secure service.
    o If, at any time, you do not want the youth to be recorded, please notify any staff by e-mail or phone of your desires. We are
         confident that these recordings will be a valuable tool for the teaching of our practitioners here at Youth Quest, and we’re
         grateful to you. If you wish, you may always choose to view the DVD/VHS before confirming your consent.
    o If you consent to video recordings between practitioners and the youth served, please sign below. Thank you very much for
         your help.

TO BE COMPLETED BY CLIENT, PARENT, OR LEGAL GUARDIAN

I have read and understand the above information and give my permission for my child to be video recorded.

                                      Date:_____/_____/_____
Parent or Legal Guardian (BEFORE ANY VIDEO RECORDINGS)

                                               Date:_____/_____/_____
Witness
                                                                Division of Mental Health, Developmental
MD/DD/SAS Contract Agency                                       Disabilities, Substance Abuse Services

CLIENT NAME                                             REC. # _______________

II. MEDICAL CONSENTS

A. General Information:

Allergies:
Physician:
Address:                                             Phone:
Dentist:
Address:
Hospital Preference:                                 Phone:
Address:

B. Consent for Medical Assistance

I understand that Youth Quest employees will make an effort to contact the above physician/dentist or take my child to the above stated
hospital. However, if certain conditions should exist, I authorize Youth Quest to call a licensed physical or dentist or take the above-
named client to the nearest doctor’s office or hospital emergency room by ambulance if necessary. Medical expenses will be paid by
me. In addition I understand that it is not reasonable for me to be contacted to consent for every minor situation that occurs in a
physician’s office; I thereby give consent for Youth Quest staff to authorize minor office-type procedures that may be recommended by
a physician and to consent for the prescription of medication deemed necessary by the treating physician for minor conditions.

If the above-named client is ill or an emergency situation arises and I cannot be reached please call and accept instructions from:

Responsible Person/s:
Address:
Telephone Number:

In the event that an emergency arises, I give permission to Youth Quest employees to administer emergency first aide or CPR as
necessary. Also, if I cannot be reached and medical treatment is necessary, I hereby give permission for Youth Quest employees to
consent to emergency medical treatment, care, or diagnosis at any hospital, public health clinic, or private physician’s office, for my
child,                        .


Parent or Guardian                            Date


Witness                                       Date
                                                                Division of Mental Health, Developmental
MD/DD/SAS Contract Agency                                       Disabilities, Substance Abuse Services

CLIENT NAME                                             REC. #______________

C. Consent for Administration of Prescription Medication

        I give permission for Youth Quest Family Teachers and Associate Family Teachers and agents to administer the following
medication(s) in the specified dosage(s) at the indicated time(s).

I release Youth Quest Inc. providers of liability on account of injury or damage to my child as related to the above.

Name of Medication                                     Dosage                               Time to be Administered

Prescribing Physician                                  Phone


Name of Medication                                     Dosage                               Time to be Administered

Prescribing Physician                                  Phone


Name of Medication                                     Dosage                               Time to be Administered

Prescribing Physician                                  Phone


Name of Medication                                     Dosage                               Time to be Administered

Prescribing Physician                                  Phone




__________________________________________                                 ___/___/___
Parent or Guardian           and Print                                     Date

                                                                         ___/___/___
Witness                                                                   Date
                                                                Division of Mental Health, Developmental
MD/DD/SAS Contract Agency                                       Disabilities, Substance Abuse Services

CLIENT NAME                                             REC. #___________

III. Transportation Consent

I,                                         hereby give my permission for Youth Quest employees to transport
     (Name of parent, or legal guardian)

                                    to and from any place the home feels the client needs or wants; recreational activities, doctor
             (Name of client)       office, etc.

I will not hold Youth Quest employees responsible for any injuries that may occur while this service is being rendered. I understand
that I may revoke this consent at any time except to the extent that action based on this consent has been taken.

This authorization is fully understood and is made voluntarily on my part. This consent is effective until termination, but not to exceed
one year.

Other persons who have permission to transport to and from program activities include:
1.
2.
3.
4.
5.



Parent or Guardian                            Date


Witness                                       Date

         This consent is signed on a voluntary basis. I understand that I may revoke this consent at any time. I will not hold Youth
Quest or its employees responsible for injury to my child while he or she is in their care. My signature certifies my understanding and
agreement with all of the above consents.
                                                              Division of Mental Health, Developmental
MD/DD/SAS Contract Agency                                     Disabilities, Substance Abuse Services

CLIENT NAME                                            REC. # _______________

                            CONSENT FOR ADMINISTERING NON-PRESCRIPTION MEDICATION

I hereby agree, as guardian, custodian, or parent of                                 to allow Youth Quest staff to administer the
following non-prescription medications only as needed by my child.
                                                          EXTERNAL
 Medication                                                         For Treatment Of:

 Neosporin or Antibiotic Ointment                                   Minor Burns, Cuts, Abrasions

 Calamine Lotion (with or without Phenol), Hydrocortizone           Allergic Rashes (Poison Ivy, Poison Oak, etc.)

 Rubbing Alcohol                                                    Insect Bites

 Betadine Scrubs or Soap and Water                                  Cleaning Area of Minor Injury

 Other (specify)
                                                            INTERNAL


 Medication:                                                        For Treatment Of:

 Acetaminophen Tablets (Tylenol,)                                   Headaches or Minor Pain
 Ibuprofen Tablets (Advil, Motrin, etc.)                            Headaches or minor pain

 Antacid tablets                                                    Indigestion, heart burn, etc.

 Cough and Cold medicine                                            For the relief of cold and flu symptoms

 Pepto Bismal Liquid                                                Upset Stomach

 Kaopectate Liquid                                                  Diarrhea

 Destromethorphan Lozenge and Spray                                 Cough

 Cepacol or Chloraceptic Lozenge                                    Sore Throat

 Benadryl Capsules                                                  Allergic Reactions (Bee Stings)
 Multivitamins or other vitamins                                    Nutritional supplement

 Other (specify)

Please XXXX out above if your child has a known allergy to any of these medications or you have an objection to the administration
of any of these medications.

                                            ___/___/___                ___________________________            ___/___/___
Name of Parent, Guardian, or Custodian         Date                    Physician’s Signature                     Date

These non-prescription medications are to be dispensed according to package directions and only for the symptoms listed on the
package labeling. This does not apply to children with complicated medical conditions or allergies to medication. If symptoms
persist, the child’s physician must be consulted.
This form is part of the admission process for all youth entering Youth Quest.
                                                                                    Division of Mental Health, Developmental
MD/DD/SAS Contract Agency                                                           Disabilities, Substance Abuse Services

                           YOUTH QUEST - INTAKEINFORMED CONSENT
THE GOALS OF YOUTH QUES’S TEACHING FAMILY TREATMENT PROGRAM

_____ The client, or legally responsible person, I understand that Youth Quest is prepared to answer any questions I may have about
this informed consent policy and/or any other policies.

_____ I understand that Youth Quest will share all confidential information with members of the team which include Youth Quest
staff, case managers, court counselors, physician, and therapist. Every effort will be made to obtain a Release of Client Information
form from the parent or legal guardian prior to sharing confidential information with those outside of the team. Confidential
information may be shared without consent.

_____The client, or legally responsible person, I understand that Youth Quest adheres to the Teaching Family Treatment Program
outlined by the Teaching Family Association. While the treatment program has flexibility in its motivation systems based on the
client’s level of cooperation and progress, Youth Quest has no other service available to the treatment of clients. The client or legally
responsible person has the right to consent or refuse treatment with Youth Quest. A voluntary client’s refusal of consent shall not be
used as the sole grounds for termination or threat of termination of service unless all systems that the Teaching Family Treatment
Program offers prove not viable.

_____ As the client, or legally responsible person, written consent will be required for, but not limited to, the prescription or
administration of the following drugs:
                   1) Antabuse; and
                   2) Depo-Provera when used for non-FDA approved uses

_____As the client, or legally responsible person, I understand that Youth Quest’s alleged benefits to the client include, but are not
limited to:
          A. Decreased runaways                        G. Increase in realistic and positive
          B. Improved grades                                youth perceptions of level of progress
          C. Decreased absenteeism                     H. High consumer satisfaction
          D. Decrease in physical confrontations        I. Decrease in use of seclusion methods
          E. Decreased legal offenses                      of interactions
          F. High youth satisfaction                   J. Increase in physical and dental health

_____The client, or legally responsible person, I understand that Youth Quest’s potential risks include, but are not limited to:
         A. A decrease in individualized care which might be available in a treatment foster care setting due to residential treatment
being a group care setting.
         B. The potential abuse from other clients in the home including, but not limited to emotional abuse, physical abuse, sexual
experimentation and/or abuse, and non-contact sexual abuse.
         C. Possible modeling of other client’s negative behavior in the home (e.g. running away, depression, suicide ideation).

_____As the client, or legally responsible person, I understand that Youth Quests possible alternative methods of treatment are
limited to the Teaching Family Model. Within the confines of the program, Youth Quest offers three basic motivation systems which
are the Daily Point System, the Weekly Point System, and the Achievement System. If the client is having difficulty complying with
the most basic system (Daily Point System), Youth Quest offers various custom Sub-Systems of treatment.

I, _______________________ (the client, or legally responsible person) have read and understand my informed consent to the Family
Teaching Treatment Program at Youth Quest. I agree to give consent for treatment at Youth Quest. As a client, or legally responsible
person, my refusal of consent shall not be used as the sole grounds for termination or threat of termination of service unless all systems
the Teaching Family Treatment Program offers prove not viable.
____________________________                 _____/_____/_____        ___________________________                  _____/_____/_____
Parent or Guardian                                  Date              Client

_______________________                   _____/_____/_____
Witness                                          Date
                                                                                   Division of Mental Health, Developmental
MD/DD/SAS Contract Agency                                                          Disabilities, Substance Abuse Services

                                                   CLIENT MEDICAL STATEMENT

Youth Quest must have this medical statement on file in the CLIENT record file. In order to protect the treatment providers (Family
Teachers and Associates), and all clients receiving care at Youth Quest, there must be on file an annual medical statement for every
client. Staff can assist with this statement after placement if necessary.

I. To be completed by the Treatment Provider:

           NAME:                                       DATE OF BIRTH: ___/___/___

           HOME ADDRESS: _______________________________________________

           TELEPHONE NUMBER: (                )

II. To be completed and signed by a physician, physician’s assistant, or certified practitioner:

In your opinion, is this person free of any communicable diseases or serious mental or emotional handicaps that would be harmful to
others living in the group home; small children, adults, and other clients?

                                                             YES          NO
If no, please explain:


General physical condition:


Evidence of required Tuberculin Test:
Type of Test:                          Date Given:
Results          POSITIVE         NEGATIVE


Signature of Physician, Physicians Assistant,
or Certified Practitioner

Address:



Phone #:
Date:    /     /




CLIENT FORM A.1
                                                               Division of Mental Health, Developmental
MD/DD/SAS Contract Agency                                      Disabilities, Substance Abuse Services




                                          YOUTH QUEST
                                     CLIENT RIGHTS HANDBOOK
                                    VERIFICATION OF RECEIPT

I have been provided a personal copy of the Youth Quest Client Rights Handbook.

I understand the expectations outlined in the code and will discuss with staff what questions that arise

on behalf of the client. I understand the procedures I may take to mediate any allegations

or concerns. Every effort will be made to clarify or explain any policies in the code.

                                                        ___/___/___
Signature Parent/Guardian                               Date

                                                        ___/___/___
Signature Client                                        Date

                                                        ___/___/___
Witness                                                 Date
                                                           Division of Mental Health, Developmental
MD/DD/SAS Contract Agency                                  Disabilities, Substance Abuse Services




Physician’s Order for Medication Administration
CLIENT NAME                                             REC. # __________


YOUTH QUEST RESIDENTIAL TREATMENT FACILITY                         Date:

I prescribe and authorize the administration of the following medication(s), according to the
below listed specifications, to the above named client:

1.

2.

3.

4.

5.

In addition, for the following topical medications, I authorize the above named client to self-
administer the following medication(s) according to the prescription with staff supervision:

1.

2.



Physician’s Signature                         Date:


Printed Name
                                                                     Division of Mental Health, Developmental
MD/DD/SAS Contract Agency                                            Disabilities, Substance Abuse Services



CLIENT NAME                                             REC. # __________

Placement: YOUTH QUEST RESIDENTIAL TREATMENT FACILITY

Consent for Church Attendance:
         Youth Quest affirms that moral and ethical training is extremely important in the development of any
adolescent. We believe that this training and teaching is a need and a right for every client to receive. We
support and embrace any sources of religious or moral training the clients receive. While at Youth Quest, it is
strongly encouraged that the clients attend religious services with the Family Teachers. We have no expectation
that clients agree with all the teachings or join the denomination the Family Teachers attend, but we feel the
moral teachings the clients receive in learning about Christ are necessary for them. We support any and all
additional sources of this important learning through relatives, friends, or other acquaintances and try to nurture
these relationships. Consent to attend the congregation with the Family Teachers does not prevent the client
from attending other services with relatives. We respectfully request that when scheduling to take your child to
church services, it is done at least 4 days in advance and in coordination with the Family Teachers. I, hereby,
give my consent for the voluntary attendance of religious services for:

                                      .
       (Name of client)


Parent or Guardian                            Date:

Policy Explanation:
        In addition, with this expectation to attend services, it can become quite chaotic when a client refuses to
go to church on the morning of the services. If this circumstance is planned in advance, other staff can be
scheduled so that the other clients and Family Teachers can attend the services. If your child refuses to attend
religious services without appropriate notice; i.e. the night or morning prior, they will earn a negative
consequence for being disrespectful to the other members of the household, only because staff could not be
scheduled in a timely manner. As we consider moral and ethical training to be a need in the lives of the
children, with or without appropriate notice, Youth Quest will provide and utilize non-denominational or non-
religious sources of teaching for all clients not attending religious services. This will be done as a study
time/forum while the other clients are attending services, refusal to participate in this forum will be grounds for
earning a negative consequence regardless of religious preferences.
                                                                             Division of Mental Health, Developmental
MD/DD/SAS Contract Agency                                                    Disabilities, Substance Abuse Services




CLIENT NAME                                              REC. #___________



                     Home Practice and Family Involvement in Treatment Policy

It is vital to the success of each client placed with Youth Quest to have the parents involved as part of the treatment team.
When reunification with the family is the discharge plan, there are mandatory home practice days for the family and
child to practice skills learned and to work towards the goal of reunification. These practice days will start gradually
and increase to full weekends and multiple weekends to practice skills. Your child will have an opportunity to earn
additional home practice days during the month that are based on earning privileges, but mandatory practice days are not
based on privilege status. There will be training on the Teaching Family Model for parents prior to your first home practice
days. There will be a review of your child’s week, skill suggestions to focus on with a review of your child’s home practice
goal sheet, and a review of the plan for support during your home practice days.

Just as teachers in school have teacher work days, home practice days are scheduled family teacher work days. Family
Teachers will be available to process your child’s behaviors and to coach you through situations in your home via phone at
scheduled increments as needed during each practice day. Family teachers can help you process consequences and
effective ways to implement the Teaching Family Model in the home. Family teachers will check in with you at least once
a day during your home practice days to ensure things are going well and to be of support to you and your child.

I understand that home practice days are a mandatory part of my child’s treatment. I understand that family teachers will be
available to process situations that may arise during home practice days during family teacher work days. I understand that
all efforts to maintain home practice days must be made before a decision is made to end a home practice day / weekend
early. I understand that I must call the family teacher or associate family teacher (if family teachers are on vacation) first to
ensure it is in the best interest of my child’s treatment to end home practice early and will need to schedule an earlier
check-in time if approved.

Home practice schedule:
Mandatory home practice days are scheduled the second and fourth weekends of the month. Family teachers will also
schedule mandatory home practice days on holidays when it’s in the best in interest of the child to be with family practicing
skills rather than in the residential treatment home.
Home practice check outs start at 11 am on Saturday mornings and check in is between 5 and 7pm on Sunday evenings.
Training on the teaching family model is offered at 10am Saturday mornings prior to picking your child up for home
practice. Any changes to this schedule need to be coordinated with the family teachers prior to schedule changes.



Parent or Guardian                         Date


Witness                                    Date



See next page for home practice schedule during treatment
                                                                          Division of Mental Health, Developmental
MD/DD/SAS Contract Agency                                                 Disabilities, Substance Abuse Services




                       Family Teacher Work Day and Home Practice Schedule
Family teachers will be scheduled for family teacher workdays the second and fourth weekend of the month. These days
may vary from one to two days depending on the plan for practice days with the family, their preparedness for longer visits
and the length of time the child has been at youth quest. Upon admission to Youth Quest, each child will be placed on a
home practice schedule.
Month 1- no out of home practice time (day practice in the home are encouraged)
Month 2 second weekend of the month (option to earn more practice time)
Month 3 Second weekend of the month (option to earn more practice time)
Month 4 Second weekend of the month (option to earn more practice time)
Month 5 Second weekend of the month (option to earn more practice time)
Month 6 second and fourth weekend of the month (option to earn more practice time)
Month 7 second and fourth weekend of the month (option to earn more practice time)
Month 8 second and fourth weekend of the month (option to earn more practice time)
Month 9 second and fourth weekend of the month (option to earn more practice time)
Month 10- review plan for discharge and create a plan according to family needs.
                                                                                    Division of Mental Health, Developmental
MD/DD/SAS Contract Agency                                                           Disabilities, Substance Abuse Services



CLIENT NAME                                              REC. #___________

Communication Restriction

I,                                         hereby give my permission for Youth Quest employees to restrict
     (Name of parent, or legal guardian)

the communication and contact of my child                                           with peers and
                                              (name of child)

acquaintances which I deem to be inappropriate for her to have contact with. Unless, specifically

identified, my child’s contact will be restricted from former/current friends or peers.

Exceptions:

This rights restriction will not include members of the treatment team or other Youth Quest clients with

whom my child will normally interact with. It will not include persons with whom interaction may occur

during the normal routine of Youth Quest approved and supervised social activities

I will not hold Youth Quest employees responsible for this right restriction I am requesting be placed upon

my child. I understand that I may revoke this consent at any time.


This authorization is fully understood and is made voluntarily on my part. This consent is effective until

termination, but not to exceed one year.

Persons not included in the above exceptions with whom my child may have contact:

1.
2.
3.
4.
5.



Parent or Guardian                            Date


Witness                                       Date

          This consent is signed on a voluntary basis. I understand that I may revoke this consent at any time. I will not hold Youth
Quest or its employees responsible for the rights restriction I am requesting. My signature certifies my understanding and agreement
with all of the above consents.
                                                                                    Division of Mental Health, Developmental
MD/DD/SAS Contract Agency                                                           Disabilities, Substance Abuse Services




                                        YOUTH QUEST TRANSPORTATION RULE

With the sharp cuts in room and board funding by 50-100%, we’ve been in a position where cuts have been needed. It’s also been our
desire to see where our limited resource of staffing is not utilized effectively.

Due to the rise in gas prices and the impacts long drives have on our increased staffing requirements, effective immediately, Youth
Quest will no longer be providing transportation to any services which require more than a 20 mile drive. Both new and existing
clients will be subject to this rule. This will include all services such as visits to the dentist, doctor, therapy, team meetings, etc.

We understand that this rule may cause a temporary disruption in some current clients’ services, but unfortunately, exceptions to this
rule will not be made. Parents may choose to transport their child to and from any preferred provider they wish to continue services
with who are 20 miles or more from the home.

For service providers who work outside of the 20 mile radius rule, we are happy to have you travel to our office for any services you’d
like to provide at our central office location which is in southwest Durham when the child resides within 20 miles of the office. For
some services, you may be able to provide the service at the facility or in the therapeutic foster home where your child resides if
permission is given by the Family Teachers and the team feels this is appropriate. Some services are required to be at a separate
facility in the case of the Quest.

In helping with this transition, Youth Quest is happy to recommend local providers in the area for therapy, dentistry, medical care, etc.

Feel free to contact the Family Teachers about this memo if you have any further questions or concerns?

				
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