Kemetic Services, LLC

Application / Preliminary Assessment

Applicant General Information
Race  





Family Information




Legal Information
Does Applicant have a Court-Appointed Guardian?    
Adjuticated Incompetent?  
Will  
Legal Status  
Marital Status  
Criminal Justice Status  
Education
Special Education    
Years Completed  





Communication
Communication Methods  




Hearing Impaired?  
Primary Diagnosis
Developmental Disability  








Intellectual Disability  





Psychiatric Disability  






Does Applicant have any psychiatric, medical or behavioral needs?  
Admissions

Financial Resources
Type  






Frequency  




Does the individual have a representative Payee?  
Medical Insurance
Medicaid  
Medicare  
MCO  





Other Medical Insurance?  

Allergies  



Kemetic Services, LLC

Skills and Behaviors Checklist

Please click each one and choose the appropriate option:


















Kemetic Services, LLC

Individual Screening Documentation Sheet

Presenting Needs Including Situation  
Reason why the individual is requesting services
Kemetic Services, LLC

Admission Packet / Screening Information

General Individual Information
Medical Information
Please list both prescription and over-the-counter medications


History of Seizures  
Special Diet  
Allergies  
Signature of Patient or Legal Guardian – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Kemetic Services, LLC

Initial Assessment

Presenting Needs Including the Individual’s:  



Kemetic Services, LLC

Comprehensive Assessment

Psychiatric and Substance Use Issues Including Current Mental Health or Substance Use Needs, Presence of Co-Occurring Disorders, History of Substance Use and Abuse, and Circumstances that Increase the Individual’s Risk for Mental Health or Substance Use Issues:

Kemetic Services, LLC

Fall Risk Assessment

This form is used to assess the potential fall risk of an individual being served
Please score each line using the scale below:
4 = High Risk - individual requires close monitoring, supervision and mobility assistance due to a history of falling
3 = Moderate Risk - individual requires close monitoring, supervision and some mobility assistance due to the potential of frequent falls)
2 = Minimal Risk - individual requires occasional monitoring due to an occasional fall
1 = Low Risk - individual rarely falls and usually requires no assistance with mobility
0 = No Risk or history of falling










Kemetic Services employees will report all falls to the CEO / Program Director and complete an incident report when falls occur. A total score of 10 or more requires that this area be addressed as a health and safety issue.
Person Completing Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Kemetic Services, LLC

Medical History Form

Past Medical History
Do you now or have you ever had:




























Family History




Extended Family Psychiatric Problems Past and Present
Systems Review
In the past month, have you had any of the following problems?
General  






Muscle / Joints / Bones  




Ears  


Eyes  





Throat  




Heart and Lungs  






Nervous System  





Stomach and Intestines  









Skin  





Blood  


Kidney / Urine / Bladder  


Women Only  




Psychiatric  





















Women's Reproductive History
Have you reached menopause?    

Do you have regular periods?  

Substance Use












Individual or Guardian Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Kemetic Services, LLC

Authorized Representative (AR) Agreement

Authorized Representative for: (check all applicable)  







I am aware that the Authorized Representative is permitted by the Human Rights regulations to authorize consent for the disclosure of information, and give informed consent to treatment including medical treatment as it relates to the services provided by Kemetic Services LLC, for the above individual who currently lacks the mental capacity to make these decisions. I accept the responsibility of involving and honoring the preferences of the individual I represent in the decision making process. I understand that Kemetic Services LLC program staff will provide the opportunity to assist in this process and give any help needed to the individual I represent to ensure meaningful participation in the preparation of the services plan, discharge plan, changes to these plans and all other aspects of services received.

I further understand the following rights and responsibilities:
  • I will have the individual’s best interest in mind as decisions are made, taking into account the law and the individual’s religious beliefs and basic values;
  • I will make a good faith effort to ascertain the risks, benefits and alternatives to a proposed treatment;
  • I will inform the person I represent, to the extent possible of the proposed treatment;
  • I will attend medical treatment appointments when it is anticipated that my consent will be needed;
  • I may object to any part of a proposed medical treatment or discharge plan that requires informed consent;
  • I may give or not give authorization for disclosure of information maintained by Kemetic Services LLC regarding the individual I represent, except as required by law;
  • I will make decisions for the individual I represent in cases where the individual lacks the capacity to give informed consent;
  • I understand that the individual’s capacity for consent will be reviewed as the person’s condition warrants, or at a minimum every six months, to assess the continued need for an Authorized Representative;
  • I am aware that providers, in an emergency, may initiate, administer, or undertake a proposed treatment without my consent or the consent of the above individual. I will be notified immediately of the provision of treatment without my consent that occurred in an emergency.
  • I understand that treatment may be provided without my consent in accordance with a court order or in accordance with other provisions of law that authorize such treatment including the Health Care Decision Act (54.1-2981 et. seq.) On behalf of the individual I represent, I may request admission to or discharge from any medical treatment at any time that requires informed consent;
  • I will be notified if the individual I represent objects to the disclosure of specific information or a specific proposed treatment or if the individual disagrees with a decision I have made that requires informed consent. As required by the Human Rights Regulations, the Human Rights Advocate will be notified and a petition for a LHRC review may also be filed under 12 VAC 35-115-180;
  • At any time I determine that I am unable to continue to represent the above individual, I will provide written notice to the Program Administrator of Kemetic Services LLC.   
I understand and accept the responsibility of becoming an Authorized Representative as outlined in the Human Rights Regulations, 12 VAC35-115-146.
I agree to the recommended appointment of the above Authorized Representative
Signature of individual – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Request for Appointment of an Authorized Representative
In accordance with the Human Rights Regulations 12 VAC 35-115-146, if an individual lacks the capacity to give informed consent, the Program Administrator may appoint an Authorized Representative.
The Program Administrator recommends appointment of an Authorized Representative for the above-named individual based upon the determination indicated below:

OR


The order of priority to determine the best-qualified representative was followed as outlined in the Human Rights Regulations. The individual below is recommended to represent the above person in the capacity of an Authorized Representative. The representation will be reviewed as the individual’s condition warrants, or at least every six months.

Kemetic Services, LLC

dLCV Acknowledgement Form

acknowledge and confirm that I have been informed of and provided a copy of disAbility Law Center of Virginia as listed below:
If you need information or have a complaint about:
  • Abuse or Neglect
  • Denial of Services
  • Discrimination based on Disability
  • Seclusion or Restraint
  • Violation of your Rights
Contact dLCV at: 1-800-552-3962
Info@dLCV.org   www.dLCV.org

You have the right to contact dLCV and to do so privately.
Signature of individual – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Kemetic Services, LLC

Program Rules

During the provision of Kemetic Services LLC services, individuals shall:
  1. Refrain from the use of any abusive, vulgar, obscene, or demeaning language;
  2. Refrain from any harassing, aggressive, threatening, or assaultive conduct toward others
  3. Respect the property rights of others.
  4. Do not enter anyone else’s bedroom without permission (Group Home only).
A Kemetic Services staff member has explained the foregoing rules to me, and I have read and understood them. I understand that, if a individual engages in repeated or serious violations of these rules, the client may be discharged from the Kemetic Services Program.
Signature of Individual or Guardian – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Kemetic Services, LLC

Individual Human and Home and Community Based Services (HCBS) Rights Acknowledgement Form

acknowledge and confirm that I have been informed of and provided a copy of my Human and HCBS rights as listed below:
Human Rights
  • To be treated with dignity and respect
  • To be told about your treatment
  • To have a say in your treatment
  • To speak to others in private
  • To have your complaints resolved
  • To say what you prefer
  • To get help with your rights
  • To confidentiality
  • To the least restrictive setting
If you have questions or need help, see Dr. Alexander C. Moore, CEO (757) 337-3968 or contact:

Regional Advocate: Reginald T. Daye
     Regional Advocate, Region V
     Eastern State Hospital
     4601 Ironbound Road
     Williamsburg, Virginia 23188
     (757) 253-7061
Home and Community Based Services (HCBS) Rights
The setting services are provided in shall:
  • Facilitate individual choice regarding services and supports as well as who provides the service and support.
  • Ensure the individual’s right to privacy, dignity, respect and freedom from coercion and restraint.
  • Support full access to the greater community in an integrated fashion. This includes opportunities to engage in community life, control personal resources, receive services in the community with the same level of access as individuals not receiving Medicaid HCBS.
  • Optimize but does not regiment individual initiative, autonomy and independence in making life choices. This includes but is not limited to daily activities, physical environment and with whom to interact.
  1. Be physically accessible to the individuals
  2. Support the individual’s freedom to control their own schedules and activities as well as have access to food at anytime.
  3. Have units that are rented or occupied under a legally enforceable agreement by the individual who has at a minimum the same responsibilities and protections from eviction that tenants have under the landlord/tenant law,55.248.2 of the code of Virginia.
  4. Support individuals to have visitors of their choosing at any time.
  5. Support the individual’s privacy while they are sleeping or living in the unit by:
    1. Units have entrance doors lockable by the individual with only appropriate staff having keys to doors.
    2. Individuals sharing units have a choice of roommates.
    3. Individuals have the freedom to furnish and decorate their sleeping or living units within the terms of their lease.
Modifications
Any modification of these requirements specified in items 2-5 above must be supported by a specific assessed need and justified by documentation in the person-centered service plan as follows:
  • Identify a specific and individualized assessed need.
  • Document less intrusive methods of meeting the need that has been attempted but failed to work.
  • Document the positive interventions and supports used prior to any modifications to the person-centered service plan.
  • Regular collection and review of data to measure the ongoing effectiveness of the modification.
  • Informed consent of the individual
  • Established time limits for periodic reviews to determine if the modification is still necessary or can be stopped.
  • Include an assurance that interventions and supports will cause no harm to the individual.
Staff Training
  • All Kemetic Services staff will be trained on the HCBS rights in conjunction with the mandated training required by 12VAC35-115; questions regarding these rights will be included in the objective written test administered during the initial staff in-services and annually.
  • Elements of the listed rights and practices for implementation are included as appropriate in both the position descriptions and the performance evaluations to emphasize the importance of the HCBS rights.
Signature of Legally Authorized Representative – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Kemetic Services, LLC

Accident / Illness Treatment Authorization

  to receive emergency medical treatment, I authorize Kemetic Services to obtain such care from his/her personal physician, or any-qualified physician available at the scene. In the event of a medical emergency, I authorize a qualified physician to performany life-saving procedures in the best interest of my health, safety, and welfare.
Signature of Individual, Legal Guardian, Authorized Representative and/or Power of Attorney – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
I authorize Kemetic Services to provide or obtain emergency medical treatment as deemed necessary. I relieve Kemetic Services of any liability for the cost of medical care in the event of illness or accident, while I am in the care of the Kemetic Services program. The individual / receiving services and / or their Authorized Representative are responsible for any charges for services stated above. Kemetic Services will not be responsible for charges for emergency services.
Signature of Individual – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Signature of Legal Guardian / Authorized Representative / Power of Attorney – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Kemetic Services, LLC

Emergency Medical Information

Police / Fire / Rescue 911      Poison Control Center 1-800-552-6337
Whom to Contact in an Emergency

Advance Directive?  
- If yes, please provide staff a copy
Able to communicate verbally in an emergency?  

Any History of Substance Abuse?  

Allergies
Signature of Person Providing the Above Information – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Kemetic Services, LLC

Audio/Visual and Video Surveillance Policy


Complete the area for the appropriate program being admitted to.
Audio/Visual and Video Surveillance Policy for In-Home Services
I give my permission to Kemetic Services to photograph, film, and/or tape record me, with knowledge, in regards to my services received through KEMETIC SERVICES. I also give my permission for this information and material, as well as identifying information (i.e. name, age, disability, work/training background, job task) to be used for professional training, publication in the KEMETIC SERVICES newsletter and community awareness of the KEMETIC SERVICES program.

My signature below indicates that I give my permission to Kemetic Services LLC to photograph film and/or tape record me and/or to be monitored by random or fixed video surveillance equipment while participating in KEMETIC SERVICES programs.
Signature of Individual or Guardian – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
      - OR -
Audio/Visual and Video Surveillance Policy for Group Home Services
I give my permission to Kemetic Services LLC to photograph, film, and/or tape record me, with knowledge, in regards to my services received through Kemetic Services. I also give my permission for this information and material, as well as identifying information (i.e. name, age, disability, work/training background, job task) to be used for professional training, publication in the Kemetic Services newsletter and community awareness of the Kemetic Services program.

In order to help insure the safety of individuals served, employees and Kemetic Services property, in Group Home settings only, Kemetic Services reserves the right to monitor its facilities in the common living areas such (as living room, hallways, dining room, laundry room, yards, front and back door) and/or vehicles via video cameras. Bedrooms and bathrooms will never be videotaped.

My signature below indicates that I give my permission to Kemetic Services LLC to photograph film and/or tape record me and/or to be monitored by random or fixed video surveillance equipment while in the common living areas of the group home and/or vehicles during the time I reside at the group home located at 2136 Jeffrey Drive, Norfolk, VA 23518.
Signature of Individual or Guardian – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
     
Kemetic Services, LLC

Consent to Exchange Information
REACH

I understand that different agencies provide services and benefits. Each agency must have specific information in order to provide services and benefits. By signing this form, I am allowing agencies to exchange certain information so it will be easier for them to work together effectively to provide or coordinate these services or benefits.
(full name of consenting person or persons) am signing this form for
My relationship to the individual is  





I want the following confidential information about the individual (except drug or alcohol abuse diagnosis or treatment information to be exchanged):
Assessment     
Information  


Financial
Information     


Benefits - Services Needed,
Planned, and/or Received  


Medical
Diagnosis     


Mental Health     
Diagnosis  


Medical
Records     


Psychological
Records  


Educational     
Records  


Psychiatric     
Records  


Criminal Justice     
Records  


Employment
Records  


Name of Agency
     REACH - Regional, Education, Assessment, Crisis Services, Habilitation

Agency Address
     7025 Harbour View Blvd., Suite 119
     Suffolk, Virginia 23435


Phone
     1-888-255-2989
I want this information to be exchanged ONLY for the following purpose(s):  


I want information to be shared: (check all that apply)  



I want to share additional information received after this consent is signed  

This consent is good until (one year) from date of signature
  • I can withdraw this consent at any time by telling the referring agency. This will stop the listed agency from sharing information after they know my consent has been withdrawn.
  • I have the right to know what information about me has been shared, and why, when, and with whom it was shared. If I ask, the agency and / or person receiving confidential documents will show me this information.
  • If I do not sign this form, information will not be shared and I will have to contact each agency individually to give them information about me that they request.
Signature of Individual or Guardian – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Kemetic Services, LLC

Consent to Exchange Information
Kemetic Services, LLC

I understand that different agencies provide services and benefits. Each agency must have specific information in order to provide services and benefits. By signing this form, I am allowing agencies to exchange certain information so it will be easier for them to work together effectively to provide or coordinate these services or benefits.
(full name of consenting person or persons) am signing this form for
My relationship to the individual is  





I want the following confidential information about the individual (except drug or alcohol abuse diagnosis or treatment information to be exchanged):
Assessment     
Information  


Financial
Information     


Benefits - Services Needed,
Planned, and/or Received  


Medical
Diagnosis     


Mental Health     
Diagnosis  


Medical
Records     


Psychological
Records  


Educational     
Records  


Psychiatric     
Records  


Criminal Justice     
Records  


Employment
Records  


Name of Agency
     Kemetic Services, LLC

Agency Address
     2428 Almeda Ave., Suite 170
     Norfolk, Virginia 23513


Phone
     757-337-3968
I want this information to be exchanged ONLY for the following purpose(s):  


I want information to be shared: (check all that apply)  



I want to share additional information received after this consent is signed  

This consent is good until (one year) from date of signature
  • I can withdraw this consent at any time by telling the referring agency. This will stop the listed agency from sharing information after they know my consent has been withdrawn.
  • I have the right to know what information about me has been shared, and why, when, and with whom it was shared. If I ask, the agency and / or person receiving confidential documents will show me this information.
  • If I do not sign this form, information will not be shared and I will have to contact each agency individually to give them information about me that they request.
Signature of Individual or Guardian – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Kemetic Services, LLC

Consent to Exchange Information
Community Services Board

I understand that different agencies provide services and benefits. Each agency must have specific information in order to provide services and benefits. By signing this form, I am allowing agencies to exchange certain information so it will be easier for them to work together effectively to provide or coordinate these services or benefits.
(full name of consenting person or persons) am signing this form for
My relationship to the individual is  





I want the following confidential information about the individual (except drug or alcohol abuse diagnosis or treatment information to be exchanged):
Assessment     
Information  


Financial
Information     


Benefits - Services Needed,
Planned, and/or Received  


Medical
Diagnosis     


Mental Health     
Diagnosis  


Medical
Records     


Psychological
Records  


Educational     
Records  


Psychiatric     
Records  


Criminal Justice     
Records  


Employment
Records  


Name of Agency
     Community Services Board  
I want this information to be exchanged ONLY for the following purpose(s):  


I want information to be shared: (check all that apply)  



I want to share additional information received after this consent is signed  

This consent is good until (one year) from date of signature
  • I can withdraw this consent at any time by telling the referring agency. This will stop the listed agency from sharing information after they know my consent has been withdrawn.
  • I have the right to know what information about me has been shared, and why, when, and with whom it was shared. If I ask, the agency and / or person receiving confidential documents will show me this information.
  • If I do not sign this form, information will not be shared and I will have to contact each agency individually to give them information about me that they request.
Signature of Individual or Guardian – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Kemetic Services, LLC

Consent to Exchange Information
Primary Care Physician

I understand that different agencies provide services and benefits. Each agency must have specific information in order to provide services and benefits. By signing this form, I am allowing agencies to exchange certain information so it will be easier for them to work together effectively to provide or coordinate these services or benefits.
(full name of consenting person or persons) am signing this form for
My relationship to the individual is  





I want the following confidential information about the individual (except drug or alcohol abuse diagnosis or treatment information to be exchanged):
Assessment     
Information  


Financial
Information     


Benefits - Services Needed,
Planned, and/or Received  


Medical
Diagnosis     


Mental Health     
Diagnosis  


Medical
Records     


Psychological
Records  


Educational     
Records  


Psychiatric     
Records  


Criminal Justice     
Records  


Employment
Records  


I want this information to be exchanged ONLY for the following purpose(s):  


I want information to be shared: (check all that apply)  



I want to share additional information received after this consent is signed  

This consent is good until (one year) from date of signature
  • I can withdraw this consent at any time by telling the referring agency. This will stop the listed agency from sharing information after they know my consent has been withdrawn.
  • I have the right to know what information about me has been shared, and why, when, and with whom it was shared. If I ask, the agency and / or person receiving confidential documents will show me this information.
  • If I do not sign this form, information will not be shared and I will have to contact each agency individually to give them information about me that they request.
Signature of Individual or Guardian – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Kemetic Services, LLC

Consent to Exchange Information
Department of Behavioral Health and Developmental Services (DBHDS)

I understand that different agencies provide services and benefits. Each agency must have specific information in order to provide services and benefits. By signing this form, I am allowing agencies to exchange certain information so it will be easier for them to work together effectively to provide or coordinate these services or benefits.
(full name of consenting person or persons) am signing this form for
My relationship to the individual is  





I want the following confidential information about the individual (except drug or alcohol abuse diagnosis or treatment information to be exchanged):
Assessment     
Information  


Financial
Information     


Benefits - Services Needed,
Planned, and/or Received  


Medical
Diagnosis     


Mental Health     
Diagnosis  


Medical
Records     


Psychological
Records  


Educational     
Records  


Psychiatric     
Records  


Criminal Justice     
Records  


Employment
Records  


Name of Agency
     Department of Behavioral Health and Developmental Services (DBHDS)

Agency Address
     1220 Bank St.
     Richmond, Virginia 23219


Phone
     804-786-3921
I want this information to be exchanged ONLY for the following purpose(s):  


I want information to be shared: (check all that apply)  



I want to share additional information received after this consent is signed  

This consent is good until (one year) from date of signature
  • I can withdraw this consent at any time by telling the referring agency. This will stop the listed agency from sharing information after they know my consent has been withdrawn.
  • I have the right to know what information about me has been shared, and why, when, and with whom it was shared. If I ask, the agency and / or person receiving confidential documents will show me this information.
  • If I do not sign this form, information will not be shared and I will have to contact each agency individually to give them information about me that they request.
Signature of Individual or Guardian – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Kemetic Services, LLC

Consent to Exchange Information
Virginia Department of Medical Assistant Services (DMAS)

I understand that different agencies provide services and benefits. Each agency must have specific information in order to provide services and benefits. By signing this form, I am allowing agencies to exchange certain information so it will be easier for them to work together effectively to provide or coordinate these services or benefits.
(full name of consenting person or persons) am signing this form for
My relationship to the individual is  





I want the following confidential information about the individual (except drug or alcohol abuse diagnosis or treatment information to be exchanged):
Assessment     
Information  


Financial
Information     


Benefits - Services Needed,
Planned, and/or Received  


Medical
Diagnosis     


Mental Health     
Diagnosis  


Medical
Records     


Psychological
Records  


Educational     
Records  


Psychiatric     
Records  


Criminal Justice     
Records  


Employment
Records  


Name of Agency
     Virginia Department of Medical Assistant Services (DMAS)

Agency Address
     600 E. Broad Street
     Richmond, Virginia 23219


Phone
     804-756-7933
I want this information to be exchanged ONLY for the following purpose(s):  


I want information to be shared: (check all that apply)  



I want to share additional information received after this consent is signed  

This consent is good until (one year) from date of signature
  • I can withdraw this consent at any time by telling the referring agency. This will stop the listed agency from sharing information after they know my consent has been withdrawn.
  • I have the right to know what information about me has been shared, and why, when, and with whom it was shared. If I ask, the agency and / or person receiving confidential documents will show me this information.
  • If I do not sign this form, information will not be shared and I will have to contact each agency individually to give them information about me that they request.
Signature of Individual or Guardian – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Kemetic Services, LLC

Consent to Exchange Information
Department of Human Services (DHS)

I understand that different agencies provide services and benefits. Each agency must have specific information in order to provide services and benefits. By signing this form, I am allowing agencies to exchange certain information so it will be easier for them to work together effectively to provide or coordinate these services or benefits.
(full name of consenting person or persons) am signing this form for
My relationship to the individual is  





I want the following confidential information about the individual (except drug or alcohol abuse diagnosis or treatment information to be exchanged):
Assessment     
Information  


Financial
Information     


Benefits - Services Needed,
Planned, and/or Received  


Medical
Diagnosis     


Mental Health     
Diagnosis  


Medical
Records     


Psychological
Records  


Educational     
Records  


Psychiatric     
Records  


Criminal Justice     
Records  


Employment
Records  


I want this information to be exchanged ONLY for the following purpose(s):  


I want information to be shared: (check all that apply)  



I want to share additional information received after this consent is signed  

This consent is good until (one year) from date of signature
  • I can withdraw this consent at any time by telling the referring agency. This will stop the listed agency from sharing information after they know my consent has been withdrawn.
  • I have the right to know what information about me has been shared, and why, when, and with whom it was shared. If I ask, the agency and / or person receiving confidential documents will show me this information.
  • If I do not sign this form, information will not be shared and I will have to contact each agency individually to give them information about me that they request.
Signature of Individual or Guardian – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Kemetic Services, LLC

Individual Orientation Checklist

Signature of Individual or Guardian – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Kemetic Services, LLC

Plan for Supports

The state of Virginia requires all ISP's and support instructions to be signed.
A final copy of the plan and support instructions will be sent to you once it has been completed.

Nothing should be completed on this section except your signature and date at the bottom.
Outcomes and Activities
Life Area  







Skill Building    

Signature below confirms that the types, reasons/purposes, explanation, risk, and benefits regarding alternative services that might be advantageous for the person this ISP has been created for have been reviewed.
Signature of Individual – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Signature of Substitute Decision Maker – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
LuxSci helps ensure HIPAA-compliance for email and web services.