Initial Packet - English

Phone: 973-770-5505 Fax: 973-770-5557

The website/browser asks for your location which is voluntary. Caring Partners uses location information only for the purposes of verification and quality assurance.

Form Revised/Reviewed 2025-06-01
Caring Partners Initial Packet

This form is to be completed by a parent/guardian or the youth (if 18 or older). This form contains a consent for Care Management Services, Electronic Communication and Authorization to Transport Form. The link to the form is sent from the Care Manager to the newly enrolled youth and their family and is gone over during the initial visit.
- Please choose your Care Manager's name in the drop down below and then their name will appear in the "Care Manager Name Confirmation" box. Please click the button to complete the fields below in this section. If the Care Manager's name is not listed for some reason, please choose "*Not listed or unknown". If there is an error, you can skip the rest of this section.
- Care Manager Name
- Care Manager Name Confirmation (please type name exactly as it appears above)
- Staff Email
  Read Only: Click button above to complete this field.
- Extension
  Read Only: Click button above to complete this field.
- Team
  Read Only: Click button above to complete this field.
- Supervisor
  Read Only: Click button above to complete this field.
- Sup Email
  Read Only: Click button above to complete this field.
- Consent for Care Management Service & Authorization for Certain Disclosures
- Name of YOUTH
  
  First NameLast Name
- Youth CYBER ID
  Please obtain this ID number from your Care Manager. *Please enter 99 if you do not know or are unable to obtain your ID number.
- Youth Social Security Number
  Enter number with no dashes or spaces.
- Youth Date of Birth
  
  MonthDayYear
- Age of Youth
- NOTE: Youths age 14 and older are required to sign consent forms. Please ensure the youth is available to sign this form prior to submission. For youths under 18 years of age, the parent or other legally authorized person also must sign this form.
- Caregiver Name, if applicable
  
  CG First NameCG Last Name
- Caregiver Relationship to Youth
  Mother, Father, Parent, Guardian, Aunt, Uncle, Self, etc.
- Parent/Legal Guardian Name
  
  PLG First NamePLG Last Name
- Parent 2/Legal Guardian 2 Name
  
  PLG2 First NamePLG2 Last Name
- Relationship(s) to Youth
  Mother, Father, Parent, Guardian, Aunt, Uncle, Self, etc.
- Legal Authority
  parent, legal guardian, self, other
- Youth Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Parent/Legal Guardian Address same as youth address
- Parent/Legal Guardian Address, if different
  
  PLG Street Address
  
  PLG Street Address Line 2
  
  PLG CityPLG State / Province
  
  PLG Postal / Zip Code
- Mailing Address same as youth address
- Mailing Address, if different
  
  M Street Address
  
  M Street Address Line 2
  
  M CityM State / Province
  
  M Postal / Zip Code
- Youth Race (check all that apply)
- Youth Race comments
- Youth Ethnicity
- Youth Ethnicity comments
- In what language do you prefer to receive communication?
  
  Other
- Disclosures to Authorized Individuals: I understand that Caring Partners may release Protected Health Information (PHI) to a family member, friend, or other person involved in the youth’s care unless I object. I designate the following person(s) listed below as a person or persons involved with the youth’s health care and/or payment for health care, to whom the information is indicated “yes” below may be released:
- Electronic Communication Authorization Form
- In addition to phone calls, please make sure all methods of communication you would like us to use are checked (Parent email, texting, voicemails and video conferencing are pre-checked):
- Please enter parent/legal guardian/caregiver email address:
- Please enter the youth's email address:
- Please enter phone numbers
- Authorization to Transport and Waiver of Liability
  
  On occasion, there may be a need for Caring Partners to transport the youth. If the need arises, staff will only transport the youth in an agency vehicle.
- Please indicate your permission
- Transport Emergency Contact Name
  
  First NameLast Name
- Transport Emergency Contact Phone Number
  
  Area CodePhone Number
- Transport Emergency Contact Relationship
- Caregiver Signature
  
  Please draw your signature with your finger, stylus or mouse.
- Name of caregiver signing
  
  First NameLast Name
- Caregiver - Please read attestation and check box to agree.
- Parent/Legal Guardian Signature
  
  Please draw your signature with your finger, stylus or mouse.
- Name of parent/legal guardian signing
  
  First NameLast Name
- Parent/Legal Guardian - Please read attestation and check box to agree.
- Youth Signature, required if 14 or older
  
  Please draw your signature with your finger, stylus or mouse.
- Name of youth signing
  
  First NameLast Name
- Youth - Please read attestation and check box to agree.
- Are you completing this form in the physical presence of the Care Manager?
- Care Manager Signature
  
  Please draw your signature with your finger, stylus or mouse.
- Name of Care Manager signing
  
  First NameLast Name
- Care Manager - Please read attestation and check box to agree.
- DocDate
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDateHourMinutesAM/PM Option
- DocType
- Email address to send this form:
  example@example.com. If you would like a copy of this form, please enter your email address. Note: This email will be used only for purposes authorized or requested by you.
- Please visit our website to view and save forms:
  
  Caring Partners Website
  
  Under Families:
  - Family Handbook
  Coming Soon:
  - Family Support Organization brochure
  - Grievance and Appeals Policy Notice
  - HIPAA Privacy Notice
  - "What is HIPAA" brochure
  - Third Party Liability Letter
  For a wide range of information about support, resources, and services for families in Morris and Sussex Counties, please visit Morris Sussex Resourcenet.org
- Thank you for completing this form. If you have provided an email address, you will receive a copy of the form. If you have any questions about any of the content of this form, please feel free to contact your Care Manager or your Care Manager's Supervisor.
- Geo Stamp - captures location and date/time of form completion.
- Please verify that you are human.
- Should be Empty:

Caring Partners Initial Packet

Consent for Care Management Service & Authorization for Certain Disclosures

Electronic Communication Authorization Form

Authorization to Transport and Waiver of Liability