Caring Partners Initial Packet

Caring Partners of Morris/Sussex, Inc.
200 Valley Road Suite 406, Mount Arlington, NJ 07856
Phone: 973-770-5505 Fax: 973-770-5557

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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.

Caring Partners Staff Information
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 *
Staff Email
Click button above to complete this field.
Extension
Click button above to complete this field.
Team
Click button above to complete this field.
Supervisor
Click button above to complete this field.
Sup Email
Click button above to complete this field.

Electronic Communication Section
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): *

Parent/Legal Guardian/Caregiver Email, please enter below Youth Email, please enter below Texting Voicemail messages Video Conferencing (without recording)
Please enter parent/legal guardian/caregiver email address: *
Please enter the youth's email address: *
Please enter phone numbers *
Caregiver Signature

Please draw your signature with your finger, stylus or mouse. Clear
Name of caregiver signing

First Name Last Name
Caregiver - Please read attestation and check box to agree.

I attest that I am the person named above and I signed this form. By electronically signing this form, I agree that the signature will be the electronic representation of my original wet signature and will be legally binding.
Parent/Legal Guardian Signature *

Please draw your signature with your finger, stylus or mouse. Clear
Name of parent/legal guardian signing *

First Name Last Name
Parent/Legal Guardian - Please read attestation and check box to agree. *

I attest that I am the person named above and I signed this form. By electronically signing this form, I agree that the signature will be the electronic representation of my original wet signature and will be legally binding.
Youth Signature, required if 14 or older *

Please draw your signature with your finger, stylus or mouse. Clear
Name of youth signing *

First Name Last Name
Youth - Please read attestation and check box to agree. *

I attest that I am the person named above and I signed this form. By electronically signing this form, I agree that the signature will be the electronic representation of my original wet signature and will be legally binding.

Authorization to Transport Section
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 Name Last Name
Transport Emergency Contact Phone Number *

Area Code Phone Number
Transport Emergency Contact Relationship *
Caregiver Signature

Please draw your signature with your finger, stylus or mouse. Clear
Name of caregiver signing

First Name Last Name
Caregiver - Please read attestation and check box to agree.

I attest that I am the person named above and I signed this form. By electronically signing this form, I agree that the signature will be the electronic representation of my original wet signature and will be legally binding.
Parent/Legal Guardian Signature *

Please draw your signature with your finger, stylus or mouse. Clear
Name of parent/legal guardian signing *

First Name Last Name
Parent/Legal Guardian - Please read attestation and check box to agree. *

I attest that I am the person named above and I signed this form. By electronically signing this form, I agree that the signature will be the electronic representation of my original wet signature and will be legally binding.
Youth Signature, required if 14 or older *

Please draw your signature with your finger, stylus or mouse. Clear
Name of youth signing *

First Name Last Name
Youth - Please read attestation and check box to agree. *

I attest that I am the person named above and I signed this form. By electronically signing this form, I agree that the signature will be the electronic representation of my original wet signature and will be legally binding.
Are you completing this form in the physical presence of the Care Manager? *

Yes No
Care Manager Signature *

Please draw your signature with your finger, stylus or mouse. Clear
Name of Care Manager signing *

First Name Last Name
Care Manager - Please read attestation and check box to agree. *

I attest that I am the person named above and I signed this form. By electronically signing this form, I agree that the signature will be the electronic representation of my original wet signature and will be legally binding.

General Information Section
DocDate

Month Day Year
Date Hour Minutes AM/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 all forms:

Caring Partners Website Forms
- Family Handbook
- 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.
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