CONSENT FORM FOR RELEASE OF INFORMATION
I, _______________________________declare that I am:
(name of consenting individual)
the parent/legal guardian of __________________________, who was born on
____________day of __________, 19_________
OR
a minor child, born on the ________day of ___________, 19 _______, who is 16 years of age or older and who has withdrawn from parental control
OR
19 years of age or older
I HEREBY GIVE MY PERMISSION to representatives of:
___________Department of Education
___________Department of Health
___________Department of Human Resources & Employment
___________Department of Justice
___________Other (please specify)
to: _______release to __________obtain from____________________________
(Identify Department/Agency)
the following information____________________________________________________
(Describe information)
which is necessary for the development/implementation of an individual support services plan.
It is my understanding that the information which is so released/obtained shall be treated as confidential in accordance with the relevant provisions of federal/provincial law and will not be shared with any other person or agency without my consent except in accordance with such laws and with any interdepartmental protocols on the sharing of information.
This consent is given of my own free will and shall be valid for _________________unless
(Period of time)
withdrawn by me in writing
_________________________ _______________________________
Date Signature of Consenting Party Signature of Witness
WAIVER OF CONSENT
I____________________, declare that I am employed by ___________________________ .
(Name of party) (Identify dept. or agency)
I met with _______________________on ________________for the purpose of
(Identify individual) (Date)
obtaining a consent to the sharing of information for purposes of the individual support services planning process.
It is my assessment that ____________________is incapable of appreciating the nature
(Identify individual)
and consequences of the required consent for the following reasons: _________________
____________________________________________________________________
____________________________________________________________________
I therefore seek approval for the waiver of consent.
_______________________________ ____________________________________
Date Signature
Approval is hereby given for the waiver of consent to enable information to be shared for the purposes of the individual support services planning process
________________________________
Signature of Supervisor
INDIVIDUAL SUPPORT SERVICES PLAN
STRENGTHS |
NEEDS |
NOTE: To be completed after an assessment and forwarded to the Individual Support Services Manager if you are unable to attend the team meeting
INDIVIDUAL SUPPORT SERVICES PLAN
TEAM MEMBERSHIP
NAME OF CHILD:___________________________________________
DATE OF BIRTH: ____________________________
ISS MANAGER: _____________________ DATE TEAM ESTABLISHED ______________
NAME |
PHONE/FAX |
AGENCY/ADDRESS |
Note: Name of ISS Manager should appear in the list
INDIVIDUAL SUPPORT SERVICES PLAN
(Strengths & Needs Agreed by Consensus of Team)
Child/Youth
STRENGTHS |
NEEDS |
INDIVIDUAL SUPPORT SERVICES PLAN
Child/Youth
Goals To be Implemented By Environment(s) Date of Review
INDIVIDUAL SUPPORT SERVICES PLAN
SERVICE NEEDS
Child/Youth:
* Service Area (proposed review date) |
Description of Service Needs and Preferred Service Options |
Is Service Available (Yes or No) |
Who Will Be Responsible for Obtaining Service |
Person/Agency Responsible for Implementation |
Date Service Obtained |
Review Date |
* Areas for discussion could include and are not limited to: place of residence, (location and support needed); social; emotional; developmental; supportive services; health needs (physical needs, medications, procedures); equipment (personal, adaptive); materials and supplies; facilities; behavior; transportation; financial; family; vocational and career planning; recreation/co-curricular.
INDIVIDUAL SUPPORT SERVICES PLAN
SUMMARY
Child/Youth:
Comments:_______________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Signature: _________________________ _________________________
Parent
_________________________ _________________________
Child (if participant)
_________________________ _________________________
Position
_________________________ _________________________
Position
_________________________ _________________________
Position
_________________________ _________________________
Position
_________________________ _________________________
Position
INDIVIDUAL SUPPORT SERVICES PLAN
INDIVIDUAL SUPPORT SERVICES MANAGER'S RECORD
Integrated Support Services Managers will contact members on actual review date and make
appropriate notations.
GOAL/SERVICE AREA |
DATE |