Simple Intake and Terms of Use

Intake with Angels Service LLC:)Thank you for being part of our community.

*A Comprehensive review and medical form may be required to initiate services. Please make sure we have all relevant information to provide care in a safe and comprehensive manner.
Objective of this agreement: We wish to establish a successful long term therapeutic relationship and want everyone to understand the system we work in and the rules and regulations that govern our services, as well as internal policies and procedures.

By initiating services with Angels Service LLC and any contractors of Angels Service LLC you agree and consent to all current rules & regulations and policies & procedures.
Client Information
If this intake is being completed with a translator or verbally please record the reader / translators name here.
Name of Person completing this form. If DIFFERENT from the client.

First NameLast Name
Relationship between person completing or helping facilitate the completion of the form and client
CLIENT NAME (PERSON RECEIVING THE SERVICE), first and last*
We would like to be able to send email reminders about appointments and other events. At the same time we would like to protect your privacy. May we have a code or nickname to use in emails so that we may send them while maintaining your privacy?
Who should we talk to about services. Such as Mom, Dad, etc. If client's age is above 18, is this person a guardian?
What services do you want? Also, if you have a provider you want to work with please share about that here. *
(If you don't have one, write none) Medicaid Number
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Communication*

Communication via text messages or other similar platforms such as social media, are not HIPAA compliant. I understand that if I choose to use these methods of communication, I am waiving my right to HIPAA in those instances. At anytime I can change my mind about communication methods and let Angels know how to communicate with me.
Phone Number*

Area CodePhone Number
Date of Birth*
Case Manager Name*
Case Manager Number
Case Manager Email

Yes or No ? (The state looks for this information when they come to visit us so we want to make sure we have it when they come)

	Yes	No
Do you have advanced directives? *If you don't know what this is the answer is no
Do you have a occupational therapist?
Do you have speech therapist?
Diabetes. Do you have diabetes?
Seizures. Do you have seizures?
G/J Tube. Do you have a gtube or jtube?
Allergies. Do you have any allergies (including to food or medicines)?
Asthma. Do you have asthma?
C.R.P. Do you have any other cardiac, respiratory, or pulmonary illnesses?
Do you use any adaptive devices for ambulation (such as a wheelchair, cane or walker) or for communication?
I understand that I need email home@watchingfish.com to make any updates or to request copies of policies, etc.
I know and understand my rights (details below and on watchingfish.com).
I know and understand the responsibilities of myself and of Angels Service LLC
Consent to Treat: I consent to receiving services on my behalf or on the behalf of someone I have the legal right to consent to services for.
Your information is protected by HIPAA. Please email home@watchingfish.com if you would like copies of policies emailed to you.
If so answered get to some of these such as seizures we will need an action plan, we will ask for a general plan below but please expect a follow up form that is generally completed by a doctor to be requested.
Do you have a physical therapist?
Diet. Do you have any special diets?
Restrictions / Limitations. Do you have any limitations that we need to know about?

Click for more information regarding advance care planning for individuals and families.

Information found here:

What is advance care planning?

What is an advance directive?

Why do I need an advance directive?

What advance directive is right for me?

What should I do right now?

Tools available for indivdiuals and caregivers (also available in Spanish)
Yes I have received information regarding advanced directives
Waivers and Agreements
I have received a copy of the Agency Disclosure Form *

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To safeguard your protected health information and ensure confidentiality, weencrypt external electronic communication which contains your confidentialinformation. This practice is designed to provide an extra level of securityfor your personal information, specifically, it requires ther recipient to usea password to access the message. We recognize that individuals or theirpersonal representatives may choose not to receive encrypted emails for avariety of reason. In order to opt out of this requirement, we must receivewritten notification. This release is intend to serve as that notification.*

I would like my information to be encryptedI grant my permission to send electronic communications UNENCRYPTED. This permission applies to me, my team, my providers, and anyone else who needs information on my behalf, as appropriate.

With the understanding that everyone will make every reasonable effort to prevent accidents, injuries, or other mishaps, I accept and agree to the following:*

	Yes, I agree	No I don't agree
REQUIRED WAIVER: The undersigned agrees to indemnify and hold harmless ANGELS SERVICE LLC AND COLLABORATORS for any and all claims, demands, costs, expenses, including reasonable attorney’s fees that ANGELS SERVICE LLC AND COLLABORATORS may suffer as a result of any claim, action. Demand, or judgement against it arising from the participation in programming. Provided, however, that the above and foregoing shall not be construed to indemnify the ANGELS SERVICE LLC AND COLLABORATORS from any act of negligence or fault on the part of ANGELS SERVICE LLC AND COLLABORATORS.
DECLINE LIMITS SOME SERVICES: The undersigned, in case of emergency and in the event the primary contact cannot be reached by telephone, does hereby give permission for medical treatment by physician or hospital selected by ANGELS SERVICE LLC AND COLLABORATORS. Such permission shall include any and all medical treatment which is necessary or desirable in the absolute discretion of any such physician or hospital. This medical care shall include, but is not limited to: examinations, treatments, immunizations, injections, anesthesia, surgery, and other procedures, etc.
REQUIRED WAIVER: The undersigned does hereby agree to allow participation of applicant in all activities with ANGELS SERVICE LLC AND COLLABORATORS (except those specified as restricted)
DECLINE LIMITS SOME SERVICES: The undersigned gives permission for the applicant to ride in vehicles operated or leased by ANGELS SERVICE LLC AND COLLABORATORS and holds harmless the aforementioned for any accidents related to the ride.
REQUIRED WAIVER: The undersigned recognizes the right of ANGELS SERVICE LLC AND COLLABORATORS, in his/ her absolute discretion, to terminate a client's services at any time due to disciplinary or medical actions which might jeopardize the client’s or client’s / collaborators health or safety while at receiving services. The undersigned further agrees to pick up the client / return home (depending on the details of service) immediately upon being notified of such termination. Fees are nonrefundable in case of above mentioned situations.
REQUIRED WAIVER: The undersigned agrees not to receive services if client has been EXPOSED to a contagious disease within three (3) DAYS of the session scheduled time.
REQUIRED WAIVER: I understand these are only the highlights, further information is below and within our online policy and procedure manual.
REQUIRED WAIVER: Your appointment will include the following during the service time - Consultation, Program Planning and Review, Direct Service, Coaching, Caregiver / Parental Education, Notes and Receipt of Service. Receipt of Service includes a geolocation, timestamp, signature and photo verification. Signature is optional as not everyone is able to sign. Photo is required and may be of client (as some of us like to pose), numbers on house, or other client specific and chosen item. (It is the fail proof verification) Photos are never saved on devices and are only in the encrypted system. *VERIFICATION METHODS UPDATING IN 2021
REQUIRED WAIVER: I understand that as independent contractors ANGELS SERVICE LLC does NOT guarantee the quality of work, control schedule or methodology of service provision. This is highly important as any consequence of negligence is the responsibility of the contractor. Any complaints or concerns should be shared as soon as possible with ANGELS SERVICE LLC so that we may work together to resolve conflict and create actions plans for prevention of future concerns / complaints. IF WORKING WITH INDPENDENT CONTRATORS ANY RESPONSIBLILITY DUE TO NEGLIGENCE, ETC. WILL BE TIED TO THE INDEPDENT CONTRACTOR NOT ANGELS SERVICE LLC
REQUIRED WAIVER: You may work with an employee where we as an agency set quality controls and expectations of how services is provided. You may request the status of your provider any time from Angels Service LLC or from your provider directly. All providers are given an ID badge showing their status.
REQUIRED WAIVER: Providers may only provide services that we have received written permission to do from the case managers.
REQUIRED WAIVER: The undersigned will, during the course of a session with Angels Service personnel, keep any firearms on the premises stored and locked and out of sight from both clients and Angels Service personnel. This reinforces our desire to create loving, caring environments in which we can provide the best possible care to you or your loved ones.

Client Details
If a section does not apply to you, write none or NA
Who is the person we are going to be spending time with? This is the space to share about what a person loves, what they want out of life or services. Things that are special to them. Or things that really bother them too that we should know about. *
Example: I am a fun hearted little girl who loves to laugh, cuddle, play puzzles, stackers, read picture books, watch movies, and ride my special three wheeled bike. I also really hate spaghetti noodles.
What medicines are you taking? This is important in case something happens when we are out and a doctor needs to know or if you are receiving massage sometimes certain medicines can be contraindicated. *
Seizure Action Plan. What should we look out for and what do we do? Write None if there is no seizures. *
Diabetic Action Plan. What should look out for and what do we do? Write NONE if there is no diabetes. *
Asthma / Breathing / Lung Action Plan. What should we look out for and what should we do? Write NONE if there is no asthma.*
Allergy Action Plan. (provide details on what allergies there are) What do we look out for and what do we do? Write NONE if there is no allergies. *
Family specific house rules and religion can be a very important part of a persons life. Record any special house rules or cultural expectations that need to be taken into consideration in order for services to be provided in a considerate manner in the box.
What adaptive devices are you using? Wheelchair, walker, cane, speech device? Write NONE if there are none.*
Behavioral Action Plan. Please share anything we need to know. If there is no behavior action plan needed write NONE.*
If you don't have any of the above, write none.
Agreement and Consent Highlights
90 Day Reviews

As a mother to a child the founder of this agency is well versed in quarterly meetings with case managers, 60 day recerts for nursing and other professional services. In order to align with best practice monitoring we to do reviews on a regular basis. Once a year we need would like to see you, this may be in person or through a video chat, which ever works best for you. HOWEVER, IF THE SERVICE IS COMPREHENSIVE VISITS ARE EVERY 1 to 3 MONTHs OR IF THEY ARE HANDS ON SERVICES THEN EVERY THREE MONTHS.Throughout the year we will do result monitoring by reviewing notes, reaching out to you, or talking to your providers. Please feel free and encouraged to reach out whenever you like.
Updates

If you have praise, concerns, or updates regarding medications, scheduling, needs, etc. Please visit our website www.watchingfish.com and see the bottom of the page and find the section that says "I'm a Family Member or Client" There will be forms for updating your information, concerns, praise, etc. or call 720-256-8875To file a complaint with the state: Call 303-692-2910 It is highly recommended in the case of a concern to start with the main number for the agency so that we can complete the grievance and compliant procedure in order to come to a resolution. IF WE DO NOT HEAR FROM YOU OR YOU DO NOT RESPOND TO OUR REQUEST FOR AN UPDATE WE WILL ASSUME THAT ALL IS WELL WITH SERVICES AND LIFE IN GENERAL, SO PLEASE IF YOU NEED ANYTHING, LET US KNOW.
I understand that if anything changes with the waiver funding services or any other aspect of the client profile (needs, wants, diagnoses, medications, surgeries, etc.) I must directly update AngelsServiceLLC@gmail.com in order to make sure care is provided in the best way possible.
Required Release of Information
I understand that to receive services, it is an inter-agency collaboration and that information about my child and family will be shared between needed agencies for
support, planning, and developmental. This includes my local Community Center Board, State agencies, Contractors, and Inter-Disciplinarian team members.

I hereby authorize the mutual exchange of information regarding the named person and the agencies / individuals listed on this form. INCLUDING, NOTES, CLIENT DETAILS, PHOTOS, VIDEOS, OTHER WORK SAMPLES, AND PROFESSIONAL OPINIONS.

There is a focus on trans-disciplinarian teamwork, this means that professional from different backgrounds will discuss different details and strategies to improve services.

I have been fully informed of the intended use of this information sharing. I also understand that the agency / person receiving this information is obliged to maintain it in a confidential manner and it is to be used only for the purpose I have authorized. I understand that this information will be kept in a database that is password protected,and for the exclusive goal of optimizing communication, resources, and supports for (myself, child, and / or family).
SIGNATURE OF CLIENT OR LEGAL REPRESENTATIVE FOR PERMISSION TO SHARE WITH THE ABOVE.*

First NameLast Name
ANYONE ELSE YOU WOULD LIKE US TO SHARE WITH? DEPENDING ON WHO IT IS WE MAY NEED TO COMPLETE A FORMAL STAND ALONE RELEASE.
ANYONE WHO YOU DO NOT WANT US TO SHARE WITH?
Some services, such as massage therapy or certain skills acquisition or replacement programs may include specific restrictive practices in order to meet the goal. This falls outside of the restraint procedures.

*For example, range of motion, stretching, bolstering, and positioning in massage therapy may be restrictive.
*For example, hand over hand work to help with skill acquisition may interrupt a client's preferred movement pattern or activity.
Rights, Consent, Expectations and Discontinuation
It is my right as the client / family member, and my responsibility, to communicate with the agency and provider.

If I have specific techniques or programming that I would like to see I will share this with the agency so that it can be part of the plan.

Clients and families receive the most benefit when they:
· Participate in activities, ask questions and communicate openly with the provider
· Create the most comfortable environment for themselves during service time possible
· Explore recommendations and offer feedback/comments to provider at next visit
· Be alert, well rested, etc. to the best of ability

Call service coordinator to assist with finding support groups, resources and billing questions.

For Massage:
• Create the most relaxing environment for themselves based off of their personal preferences.

o Some prefer music, some prefer silence, books on tape, tv, etc
o Some want a massage that is integrated into daily living some want a spa like
Experience or even incorporate play into the massage session
o Oil, lotion, or dry, scents, etc.
Timeliness is important and we strive to begin sessions at their scheduled time but due to driving between homes and uncontrolled circumstances start time may vary 10-15 minutes at times.

If your service is time sensitive, such as the provider is the only one caring for a client after school or another caretaker will not be available to provide care, make this known so that providers can arrange schedules to accommodate the time sensitive nature of the appointment.

If at any time your provider is not providing the agreed upon service within your expected timeline, reach out an alert us directly.

· Safety is our #1 concern. Home visits may be cancelled if road conditions are poor and there are travel advisories.

-Caregivers must be present for the entire visit for early intervention.
-Other services and individualized service plans may or may not require caregiver presence during sessions.

· Please call the provider to cancel appointments. Sessions may not be able to be rescheduled. If there is less than 3 hours notice, a care conference may need to conducted. If client's do not regularly keep their appointments service may not be able to continue.

· Please note that frequency of visits may be reduced or change during holidays, vacation times, or due to a provider becoming ill. If the provider cancels the care-giving responsibility reverts to the primary caretaker unless other plans are specifically made.

· If a family is not home for a scheduled visits, does not return phone calls or other attempts to contact them, it is assumed the family does not want to participate in services and will be discharged. This will be documented and the case manager updated.

· If individual has aggressive challenges caretaker must be close at hand during sessions and is responsible for intervening and any damages unless otherwise planned for.

*Requests for schedule changes will try and be accommodated but will depend if the provider has openings.
If you are receiving Early intervention services they end at the child's 3rd birthday / family discontinues services / services is no longer needed / funding is not available.

If you wish to discontinue services you may do so at anytime. Please let us know.

If your provider become unavailable outside of basic illness or vacation we will reach out to you to discuss options such as another provider with our agency if possible or contacting your case manager for a referral. Depending on your service type, we may also contact CDHPE at the state to inform them that we cannot provide services.

If due to actions from the client or family that jeopardizes the well-being of a provider an emergency discharge will take place and case management and CDHPE will be notified within 48 hours.
I have received my written home care consumer rights. *

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Pay
Client or responsible agent is responsible for payment if insurance does not reimburse services. (Does not apply to Medicaid clients when the service is a covered service in detail, frequency, and duration).
Paperless Company
If you would like a copy of any policies and procedures please request them in writing. Otherwise, we are a paperless company and all policies and procedures are found on our website.

http://www.watchingfish.com/expectations This is our policy and procedure manual. There are also many other resources.
Need Rating

We are unable to serve critical care clients and if this is your need would like to help you find an agency with the skill set you need.
Need Rating*

Level One: We have a busy life and like to skip making up missed sessions for both when we cancel and when a provider cancels.Level Two: We have a busy life but would like to try and make up missed sessions when possible.Level Three: Making up missed sessions are a priority and too many missed sessions may result in needing additional or different providers.Level Four IRSS clients: Sessions are very important and I need them. However, I am safe and able to function if I miss up to FOUR DAYS IN A ROW OF DIRECT CARE holidays, illness, weather, or other reasons outside of comprehensive emergency.Level Five IRSS clients: Session are vital and I have a live in provider who is able to meet my needs.Critical Care All clients: Sessions are a must to my well being and are time time sensitive. I am unable to miss sessions. I need help finding an agency who is able to provide critical care.
Safety Plan

In case something happens when we are at your home. :)
We are able to print you off an emergency sheet that includes information about you, your medical background, insurance, and your safety plan so that you can keep it with you, in your emergency bag, or for visitors / first responders. Would you like a copy?

Yes pleaseNo Thank you
Emergency Contacts*
Who is the legal guardian?*
Where should we shelter if we are staying in the house, such as a tornado or storm.*
Where should we meet if we need to evacuate the house but can stay in the neighborhood?*
Where should we meet if we cannot stay in the neighborhood?*
Where is your emergency supplies?-First aid kit-Extra blankets-Flashlight and batteries-At least three days of food and water
What are the escape routes from your home ?
Any information we should provider to first responders? Such as pet information or health information?*
Preferred Primary Care Doctor*
Preferred Dental Doctor*
Preferred Urgent Care Doctor*
Preferred Emergency Room Doctor*
Signatures
Electronic Signature OF PERSON LEGALLY ALLOWED TO CONSENT TO SERVICES and all information received / submitted:
By typing your name you are signing this document and stating that you understand all the information and have provided truthful information. By signing you agree to all our policies and procedures. :)
Signature

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Signatures for the State Mandated Forms and Intake

Electronic Signature Confirmation of Receipt of Handouts*

	Confirmation of Electronic Receipt of Following Documents
Home Care Agency Rights Notice
Rights
Emergency Plan
Home Care Agency Disclosure
Complaint Process
Dispute Process

Any notes you have
Revisions:

6.28.22 Removed questions about requesting more information about advanced directivites. Add in link and headlines for CDHPE advanced directive information
Signature of receiving agency disclosure for Home Care Agency Services

First NameLast Name
Signature of receiving Home Care Agency rights notice

First NameLast Name
Should be Empty:

Intake with Angels Service LLC:)Thank you for being part of our community.

Client Information

Waivers and Agreements

Client Details

If a section does not apply to you, write none or NA

Agreement and Consent Highlights

90 Day Reviews

Updates

Required Release of Information

Rights, Consent, Expectations and Discontinuation

Pay

Paperless Company

Need Rating

Safety Plan

Signatures

Signatures for the State Mandated Forms and Intake