REACHING FOR THE STARS by hcj

VIEWS: 5 PAGES: 6

									REACHING FOR THE STARS
           TRAINING AND ACTIVITY CENTER
                  CONSUMER INFORMATION SHEET

CONSUMER INFORMATION
Name:                       DOB:                  LON
Medicaid #:                      SS#:
Address:
City:                       State:         Zip:


CONTACT INFORMATION
Contact Person:                  Relationship:
Work Phone:                      Cell Phone:
Email:


Contact Person:                  Relationship:
Work Phone:                      Cell Phone:
Email:


Contact Person:                  Relationship:
Work Phone:                      Cell Phone:
Email:



                                                        1
MEDICAL INFORMATION
Diagnosis:
Allergies:
Physician Name/Number:
Preferred Hospital:
Dietary Restrictions:


MEDICATIONS (to be administered by dayhab staff)
Medication:
Dose:                               Time:


Medication:
Dose:                               Time:


Medication:
Dose:                               Time:


OTHER INFORMATION
Company Name:                       Program:
Communication Needs:
Ambulation:
Helpful Information:




                                                   2
                       Client/Caregiver Agreement
1. Parent/guardian or case manager is responsible for notifying Reaching
   For the Stars (RFTS) when a consumer will be absent for more than
   three days.

2. RFTS is not responsible for lost, stolen, or damaged items.

3. RFTS asks that consumers refrain from using cell phones unless it is
   break and/or lunch time.

4. RFTS will notify parent/guardian/provider immediately if an illness or
   emergency should occur.

5. RFTS has the right to suspend or refuse services to a consumer if he/she
   becomes a threat to the health/welfare of other consumers or staff
   members.

6. RFTS will only supervise/assist with medications if it is in the original
   container from the pharmacy, and the nurse has provided a MAR. RFTS
   staff will not accept medications in any other type of container.



    Client signature                    Date



    Guardian signature                  Date



    RFTS Director                       Date




                                                                               3
                      Dietary Restrictions
Consumers will have the opportunity to purchase snacks/drinks at break
and lunch times. Please list any dietary restrictions that the consumer may
have so that RFTS staff can assist the consumer in making healthy choices.

Allergies:

Diet:

Any other info:




Guardian                               Date




Consumer                               Date




                                                                              4
           Consent: Photograph, Record, or Film




I,                                     , hereby authorize Reaching For The
          (guardian)
Stars to photograph, record, or film
                                              (consumer)
for the purpose of identification and/or education/training. I understand

that my picture may be used on the RFTS website for public information or

promotional purposes. RFTS has exclusive rights to any media produced

and I will not receive compensation of any type for the use of my

photograph, record, or film




     Client signature                  Date



     Guardian signature                Date




                                                                             5
         Consent: Emergency Medical Treatment


I,                                       , hereby authorize Reaching For The
          (guardian)
Stars to seek emergency medical treatment for                              .
                                                    (consumer)
This consent is given only to cover those instances which are considered

medical emergencies. RFTS policy states that the parent/guardian or

provider is contacted immediately in the case of an emergency. RFTS is not

financially responsible for any medical bills.




     Client signature                    Date



     Guardian signature                  Date




                                                                               6

								
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