TCM Forms

Step 1 of 4

TCM Goal Sheet
Client's Name*
DOB*
MM slash DD slash YYYY
Client’s presenting problem:
Goals: All goals must be TCM specific and different than current goals listed on the Treatment Plan.
Goal 1
Goal 2
Additional Goal(s):
Client/Guardian’s Signature
Date
MM slash DD slash YYYY
Please notify Therapist when TCM Services have been approved and ask them to update the Treatment Plan.

Consent to Release Information

I consent for Kentucky Mental Health Care, LLC and those representing this group to share my private health care information with the following individuals and/or entities. KMHC is permitted to send and receive information to and from the entities below if needed:
Representatives of Child’s School (School Name):*
Primary Care Physician Name:*
Emergency Contact Name:*
Other/ Self:*
I understand that I have the right to revoke this authorization, in writing, at any time by sending notice to Kentucky Mental Health Care, LLC. I understand that a revocation is not valid to the extent that Kentucky Mental Health Care, LLC has acted in reliance on such authorization. This authorization does not expire until I submit a written request. A copy of this release shall have the same force and effect as the original.

NOTICE TO RECEIVING PROVIDER OR ORGANIZATION: You may not re-disclose any of this information unless the person who consented to this disclosure specifically consents to such re-disclosure.
I understand that there is a potential for disclosure of this information by the recipient and, if that occurs, federal law may not protect the information.
Client Signature (Parent/Guardian must sign if client is a minor)*
Date
MM slash DD slash YYYY
Clinician Signature*
Date
MM slash DD slash YYYY

HIPAA NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSEDAND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Kentucky Mental Health Care, LLC has been and will always be totally committed to maintaining client confidentiality. We will only release healthcare information about you in accordance with federal and state laws and ethics of the counseling profession.

This notice describes our policies related to the use and disclosure of your healthcare information. Your health information may be used for the purposes of providing treatment services, collecting payment and conducting healthcare operations are necessary activities for quality care. State and federal laws allows us to use and disclose your health information for these purposes.

TREATMENT:We may need to use or disclose health information about you to provide, manage or coordinate your care or related services. Which could include consultants and potential referral sources

PAYMENT Information needed to verify insurance coverage and/or benefits with your insurance carrier, to process your claims as well as information needed for billing and collection purposes. We may bill the person in your family who pays for your insurance.

HEALTHCARE OPERATIONS We may need to use information about you to review our treatment procedures and business activity. Information may be used for certification, compliance and licensing activities.

There are some instances where we may be required to use and disclose information without your consent. For example, but not limited to: Information you and/or your child or children report about physical or sexual abuse: then by Kentucky State Law, we are obligated to report this to the Department of Children and Family Services; If you provide information that informs us that you are in danger of harming yourself or others, we must report this also; Information may be used to remind you of /or to reschedule appointments or treatment alternatives; Information shared with law enforcement if a crime is committed on our premises or against our staff or as required by law such as a subpoena or court order; Clinical records, psychotherapy notes and other disclosures require a separate signed release of information.

You have a right to or will receive notification of a breach of any unsecured personal health information. You have a right to restrict any disclosure of personal health information where you have paid for services out-ofpocket and in full.

METHOD OF CONTACT BY OFFICE

We may send you appointment reminders by text message or phone call and leave a voice message.

NOTICE OF PRIVACY PRACTICES AND CLIENT RIGHTS: I have read and received a copy of the Notice of Privacy Practices and Client Rights document.
Signature (Parent/Guardian must sign if client is a minor)*
Date
MM slash DD slash YYYY

TCM Forms

Step 1 of 4

TCM Goal Sheet

Goals: All goals must be TCM specific and different than current goals listed on the Treatment Plan.

Please notify Therapist when TCM Services have been approved and ask them to update the Treatment Plan.

TARGETED CASE MANAGEMENT NEEDS ASSESSMENT

Consent to Release Information

HIPAA NOTICE OF PRIVACY PRACTICES

METHOD OF CONTACT BY OFFICE

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