Client Care and Outreach Form

Client Care and Outreach Form

Parties

Service Provider:

Client Name:

Recitals

WHEREAS, the Service Provider is engaged in providing client-centered outreach, care coordination, and support services tailored to individual needs; and

WHEREAS, the Client seeks to receive outreach and care coordination services designed to address identified needs and improve client outcomes; and

WHEREAS, the parties desire to set forth the scope, terms, and conditions governing outreach activities, payments (if applicable), confidentiality, and termination of services.

Client Information

Phone Email Text Message Mail

Scope of Work

The Service Provider will perform outreach and client care services including but not limited to needs assessment, care coordination, referral and follow-up, and periodic outreach contacts as described below. Services will be provided in a manner consistent with applicable professional standards and the Client's expressed preferences.

Outreach Plan and Schedule

Needs Assessment

Indicate identified needs (check all that apply) and provide brief notes.

Housing Food Security Medical Care Mental Health Employment Legal Assistance

Consent and Information Sharing

By checking the boxes below, the Client authorizes the Service Provider to act as indicated. The Client may revoke authorizations in writing except to the extent actions have already been taken in reliance on the authorization.

I consent to outreach contacts and care coordination. I consent to limited information sharing with partner agencies for referral and care coordination. I consent to leaving messages with appointment or care information at provided phone numbers.

Payment Terms

If fees apply for services rendered, they will be charged according to the following terms. All monetary amounts are due in accordance with the agreed schedule below.

Term and Termination

The term of this Agreement begins on and continues until unless earlier terminated as provided below.

Either party may terminate services for convenience upon written notice provided at least days prior to the intended termination date. Immediate termination may occur for material breach or threats to safety.

Confidentiality

The Service Provider shall maintain the confidentiality of Client records and information in accordance with applicable law and professional standards. Confidential information shall not be disclosed except (a) with the Client's prior written consent; (b) as necessary for care coordination with authorized partners; (c) where disclosure is required by law; or (d) to prevent imminent harm. The Service Provider will take reasonable administrative, technical, and physical safeguards to protect Client information.

Governing Law

This Agreement shall be governed by and construed in accordance with the laws of the state identified by the Service Provider's principal place of business. The parties submit to the exclusive jurisdiction of the state and federal courts located in that state for resolution of disputes arising under this Agreement.

Entire Agreement and Amendments

This document, together with any written attachments or statements of work incorporated by reference, constitutes the entire agreement between the parties with respect to the subject matter herein and supersedes all prior agreements and understandings. No amendment or modification shall be effective unless in writing and signed by both parties.

Additional Provisions

The Client acknowledges that the Service Provider may subcontract certain functions to qualified partners for the purpose of delivering services. The Service Provider remains responsible for contract performance. Any disputes not resolved informally will be subject to mediation prior to the commencement of litigation, except where injunctive relief is necessary.

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