Client Information CYFD Form

CLIENT INFORMATION CYFD FORM

This Client Information and Services Agreement (the "Agreement") is entered into by the parties identified below. Client Name: Provider Name: Effective Date:

WHEREAS

WHEREAS, Client seeks assessment, case management, therapeutic and supportive services for the purposes of promoting the health, safety, and welfare of the child or youth named herein; and

WHEREAS, Provider is qualified to provide the services described in this Agreement and has policies and procedures governing the delivery and confidentiality of those services in accordance with applicable statutes and regulations; and

WHEREAS, the parties desire to document Client information and to set forth the terms under which Provider will deliver services and Client will accept such services.

CLIENT IDENTIFICATION

Date of Birth: Gender: Client ID (if any):

American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Other (specify):

RESPONSIBLE PARTY / GUARDIAN

EMERGENCY CONTACT

HEALTH AND INSURANCE

CONSENTS & AUTHORIZATIONS

I consent to assessment and provision of services by Provider as described in this Agreement.

I authorize Provider to release and receive information as necessary for care coordination and billing, subject to applicable privacy laws.

I acknowledge that Provider is required by law to report suspected abuse, neglect or imminent risk to the appropriate authorities.

SCOPE OF WORK

Describe the services, goals, and expected deliverables below:

PAYMENT TERMS

Total Fee / Rate: $ Billing Contact:

Late Payment Fee: Billing Terms:

TERM AND TERMINATION

Start Date: End Date:

Either party may terminate this Agreement for convenience by providing written notice to the other party not less than days prior to the effective termination date. Provider may terminate immediately for cause if Client materially breaches obligations or if continued provision of services would violate law or professional standards.

CONFIDENTIALITY

Provider and Client shall treat all client records, communications, and personally identifying information as confidential and shall not disclose such information except as permitted by law, this Agreement, or pursuant to a signed release. Provider will implement reasonable administrative, technical and physical safeguards to protect client information. Confidential obligations survive termination to the extent necessary to protect the confidentiality of records and privileged information.

GOVERNING LAW

This Agreement shall be governed by and construed in accordance with the laws of the state in which Provider maintains its principal place of business, without regard to conflicts of law principles.

ENTIRE AGREEMENT

This Agreement, including any incorporated client information and scopes of work, constitutes the entire understanding between the parties with respect to the subject matter herein and supersedes all prior and contemporaneous agreements, representations, and understandings, whether written or oral. Any modification to this Agreement must be in writing and signed by both parties.

CERTIFICATION

By signing below, Client and Provider certify that the information provided on this form is true and correct to the best of their knowledge, that Client consents to the services and terms set forth herein, and that Provider has explained the limits of confidentiality and mandatory reporting obligations.

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