OFFICE USE ONLY Admission Date _______________________ FSW _________ Classroom _____________ Service TBS + Extended Care Gotcha Therapy PT OT SP MH Medicaid Match DSS UW APPLICATION 254 Requested ________________________ Payment ABC V SNV Bus: Morning Self Pay $________ Afternoon Name of child Date of birth □ Copy of Birth Certificate Address________________________________________City _________________ Zip Code ______________ Gender ____________ Social Security Number _________________ Medicaid Number___________________ □ Copy of card □ Copy of Card Mother’s Name ____________________________Address (if different) __________________________________ SS Number _________________ Date of Birth _______________ Last School/ Grade Attended ____________ Mother’s phone (Home) (Work) Work Hours ___________________ Father’s Name _____________________________Address (if different)__________________________________ SS Number _________________ Date of Birth _______________ Last School/ Grade Attended ____________ Father’s phone (Home) (Work) Work Hours Who lives in the home? Has child had any previous child care experience? Where? _________________________________________ Doctor __________________________ Referred by: ______________________________________________ Parent’s Signature Date POLICIES: DISCIPLINE Child’s Name____________________________________ Children’s Place, Inc. regards discipline as teaching appropriate forms of behavior, not as punishment. We believe that discipline should build self-worth, increase social competence, teach problem-solving skills and enhance the dignity of the child. Positive discipline begins by preventing problems from happening. Our program is designed to give children an environment that helps them manage their own behavior. Here rules are for everyone. Each child is introduced to our four (4) rules. 1. We do not hit each other. 2. We do not hurt our belongings. 3. We do inside things inside and outside things outside. 4. We take care of ourselves. Even when the staff has done everything they can to avoid trouble, it may still occur. Our standard practices are: 1. We allow natural consequences to happen. EXAMPLE the child’s food may get cold if they dawdle when washing their hands 2. We enforce logical consequences. EXAMPLE if a child spills milk; they have to clean up the spilled milk 3. Children are given choices that redirect their behavior. EXAMPLE if they are running in the classroom; they would be stopped and asked what center they want to play in, blocks or puzzles 4. If children are hurting each other, they are protected and assisted with expressing their thoughts and feelings EXAMPLE “DON’T HIT ME ANYMORE. I’M ANGRY WHEN YOU HIT ME!” 5. If a child is hurting other children. They are asked to leave the group for a few minutes, and get themselves together. This is called time-out. 6. When children are out of control and a danger to themselves or others, the staff demonstrates control, reassurance and acceptance by holding the child and talking to him quietly until the child is in control of him/herself. This is called a therapeutic restraint. If children have special behavioral needs, the treatment team at Children’s Place meets and designs a plan of intervention services called a treatment plan. Parents participate in the planning and the review process. Time-out maximums are one minute for each year of age. We DO NOT USE: 1. Corporal punishment – which includes spanking, slapping, biting, hitting, shaking, etc. 2. Deprive a child of food, water, naps or bathroom facilities 3. Unsupervised isolation 4. Improperly restricting children’s movement, such as tying a child to a chair We ask parents to refrain from any form of corporal punishment while on the premises of Children’s Place. _________________________________________________ NAME DATE One must be signed yearly in August _______________________________________________ WITNESS RELEASE: AUTHORIZATION TO TREAT Children's Place, Inc. is a family resource center providing year-round Therapeutic Behavioral Services; Parenting Services, and counseling and treatment services for children. On our site, we serve children in two additional levels of care; regular childcare and special needs childcare. Services are provided in a classroom where all children receive the level of service for which they are referred. This approach is called inclusion-based services, and it allows children to learn from one another as well as from the professionals. We use the help of many professionals whose areas of specialization may include education, social work, mental retardation, psychology, psychiatry, speech therapy, occupational therapy, physical therapy, counseling, and medicine. Children are observed in the classroom by these professionals and screened for additional service needs. The staff of Children’s Place participates in a community-based multi-disciplinary team. We consider this form of community consultation to be essential to our treatment program. Team members are all required to maintain confidentiality. Team members include: Aiken County DSS, 2nd Circuit Solicitors Office, Wagner Police Department, Aiken County DJJ, Aiken County Guardian-Ad-Litem Program, Aiken Department of Public Safety, Aiken County Public Schools, Aiken-Barnwell Mental Health, Aiken County Sheriff’s Department, Helping Hands, Aiken Center for Alcohol and Other Drugs Services, North August Department of Public Safety, and the Aiken County Department of Health. A part of the services provided at Children's Place, Inc. is billing the funding source for payment of our fees. This could be Medicaid, SOVA, ABC Vouchers, or ABC Special Needs Vouchers. Part of the Medicaid funding will include notifying United Way of Aiken County so they can release match funding for Medicaid. __________________________________________________________________________________________ I understand that signing my name gives the staff of Children's Place, Inc. permission to bill my payment source and for all the treatment services to begin. ________________________________________________ SIGNATURE DATE ____________________________________ WITNESS PARENT AGREEMENT Please initial statements that you agree to: _____ I have been given a Child Care Handbook. _____ I agree to follow the procedures in the handbook including: Arrival Time Home Visits (if applicable) Program Hours and late fees Fees (if applicable) Ill Children Medication Discipline Birthdays Outside Play Meals & Snacks Holidays and School Closing Policy Approved Adults to Pick-up with ID _____ I hereby grant permission to the Children’s Place, Inc., to record, magnetically (i.e. audio tapes) or digitally (i.e. video), or to photograph my child for the purpose of education, assessment, program evaluation and public release of information (newspapers, magazines, brochures). _____ I hereby grant permission to Children’s Place, Inc. to take my child on neighborhood walking trips (i.e. looking for leaves, houses, and birds). _____ I will complete a Special Care Plan with staff for my child and follow it, if applicable. I give permission for my child to have sun block and/or mosquito repellant applied. (Only for 2 years+) _____ I agree that my child will be transported to the program by . _____ My child’s arrival time will be . . His/her departure time will be _____ I give permission to Children’s Place, Inc. to transport my child to All Saints Anglican Church at 110 Fairfield Street in the event of an immediate emergency evacuation. I understand that I will be notified as soon as possible and that my child will be cared for until I can pick him/her up. Child’s Name Date Parent Signature As needed or yearly in August RELEASE: EMERGENCY TREATMENT LETTER OF ATTORNEY TO WHOM IT MAY CONCERN: As the parent(s) or guardian(s) of __________________________________________ (Name in Full) and realizing that the above named child may require emergency medical attention or medication, I/we hereby authorize the Children’s Place, Inc. (hereinafter referred to as the “Center”) to act as attorney-infact in my/our capacity as parent(s) or guardian(s). In order to secure medical treatment from qualified medical personnel and/or establishment on behalf of the above named child. Said authority shall include, without limitation, the disclosure of information regarding the child, the execution of documents for treatment or admission, the giving of informed consent by the Center for needed medical procedures, and any and all sundry acts as might be required of me in procuring emergency medical treatment for said child. By granting this authority, I/we hereby agree that any and all acts of the Center accomplished hereunder shall be construed as my/our acts and shall bind me/us and I/we hereby agree to hold harmless the Center from any financial obligations incurred for emergency medical treatment for the above-named child. PARENT/GUARDIAN DATE WITNESS DATE Family Doctor’s Name Doctor’s Phone Number List all known allergies: _____________________________________________ SPECIAL CARE PLAN 1. Describe your child’s special needs: 2. What emergency situations might happen while your child is in our care: 3. What do we need at Children’s Place to care for your child: 4. What are the particular instructions for sleeping, toileting, diapering, or feeding: 5. What are the special emergency and /or medical procedures required: 6. What special training must the staff have to provide that care: 7. Who are the other specialist working with the child (OT, PT, Nurse, LSP): Primary Case Manager Address Phone NOTICE OF PRIVACY PRACTICES The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. “HIPAA” provides penalties for covered entitles that misuse personal health information. As required by “HIPAA”, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information. We may use and disclose your medical records only for each of the following purposes: treatment, payment, and health care operations.  Treatment means providing, coordinating, or managing health care and related services by one or more health care providers.  Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review, an example of this would be sending a bill for your visit to your insurance company for payment.  Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer services. An example would be an internal quality assessment review. We may also create and distribute identified health information by removing all references to individually identifiable information. We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization. You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Executive Director or the Board of Directors.  The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family member. If we do not agree to a restriction, we must abide by it unless you agree in writing to remove it.  The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.  The right to inspect and copy your protected health information, there may be a fee to do so.  The right to amend your protected health information.  The right to receive an accounting of disclosures of protected health information.  The rights to obtain a paper copy of this notice form us upon request with a fee. We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information. This notice is effective as of April 14, 2003 and we are required to abide by the terms of the Notice of Privacy practices currently in effect. We reserve the right to change the terms of our Notice of Privacy practices and to make the new notice provisions effective for practices from this office. We have recourse if you feel that your privacy protections have been violated. You have the right to file written complaint with our office, or with the Department of Health & Human Services Office of Civil Rights, about violation of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint. To get more information or file a complaint please contact: Children's Place, Inc. DHHS-Office of Civil Rights 310 Barnwell Ave., NE 200 Independence Avenue, SW Aiken, SC 29801 (803) 641-4144 Washington, DC 20201 Acknowledgement Receipt Notice of Privacy Practices Health Insurance Portability & Accountability Act (HIPAA) I acknowledge receipt of the Notice of Privacy Practices - Health Insurance Portability & Accountability Act (HIPAA) from Children’s Place, Inc. I am also aware that if I have any questions about the Privacy Practices/HIPPA, I can talk with any staff member or contact the Executive Director, the HIPAA Privacy Officer. Child’s Name (Print) Signature of Parent/Guardian/Personal Representative Print Name (Parent/Guardian/Personal Representative) Date of Parent/Guardian/Personal Representative’s Signature AUTHORIZATION FOR RELEASE AND USE OF INFORMATION I, ________________________________________ give permission for the release and use of information pertaining to (DOB) . By checking both “to” and “from” below, you authorize the release and receipt of information. You are also giving us permission to communicate with the below mentioned party and for them to communicate with us. TO: ____ FROM: Children’s Place, Inc. 310 Barnwell Avenue NE Aiken, SC 29801 Attn: ___ TO: ____ FROM: ____ Name: AIKEN COUNTY HEALTH DEPT Address: 828 Richland Ave. W City/State: Aiken, SC 29801 Phone: 803.642.2141 The information will be used to plan and coordinate the care of my child and/or family. This release is in effect for 5 years from the date on the release or until the release is rescinded by the parent, guardian, or the child if the child is of legal age. To rescind the release a parent or guardian will simply put that request in writing. Parent/Guardian Signature Date Witness Signature Staff member to be contacted for additional information AUTHORIZATION FOR RELEASE AND USE OF INFORMATION I, ________________________________________ give permission for the release and use of information pertaining to (DOB) By checking both “to” and “from” below, you authorize the release and receipt of information. You are also giving us permission to communicate with the below mentioned party and for them to communicate with us. TO: ____ FROM: Children’s Place, Inc. 310 Barnwell Avenue NE Attn: ___ TO: ____ FROM: ____ Name: _____________________ Address: ___________________ City/State: __________________ Phone: _____________________ The information will be used to plan and coordinate the care of my child and/or family. This release is in effect for 5 years from the date on the release or until the release is rescinded by the parent, guardian, or the child if the child is of legal age. To rescind the release a parent or guardian will simply put that request in writing. Parent/Guardian Signature Date Witness Signature Staff member to be contacted for additional information RELEASE: CONSENT FORM Parent Name: ________________________________ Phone No.:__________________________________ Address:____________________________________ The Children’s Place, Inc. staff has my consent to release my child __________________________________ to the care of the following individuals in my absence. NAME ADDRESS PHONE ADD REMOVE INITIAL Parent Signature _____________________________________________ Date___________________________ Witness___________________________________ Signature, Relationship Only the above listed persons with a photo I.D. will be able to pick your child up at school or accept your child off the bus in the afternoon.