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The Penelope Group HCBS/CFTSS Form
Should you need assistance or have questions. Please contact us.
Healthcare Advocate: Nathaniel Fleming
Contact# 929.483.6870
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* Indicates required question
Child or Client Section
Child or Client Primary Information
Child/Client First Name
*
Your answer
Child/Client Last Name
*
Your answer
Date of Birth:
*
MM
/
DD
/
YYYY
Age:
*
Your answer
What school is the
Child or Client
currently attending?
*
Your answer
Does the
Child or Client
have an
IEP and/or 504 Plan
?
*
IEP
504
Unsure
None of the Above
Required
Does the
Child's or Client's
family or household have members living with
illness or disabilities
? (Example: Heart disease, High Blood Pressure, Diabetes, Dementia, Alzheimer, Cancer etc.)
*
Yes
No
Unsure
If you have selected "
Yes"
in the question above and know the name of the
illness or disabilities
. Please provide it below.
Your answer
Has the
Child's or
Client's
family or household experienced
trauma
?
*
Yes
No
Unsure
If you have selected "
Yes"
in the question above and would like to briefly explain the experiences. Please provide it below.
Your answer
Has the
Child's or Client
's
family or household experienced anyone living with a
Alcohol/Drug use issues
?
*
Yes
No
Unsure
How urgent does the
Child or Client
need
HCBS/CFTSS
?
Immediately
Soon
Clear selection
Parent or Legal Guardian
Primary Contact Information
Parent/Legal Guardian First Name
*
Your answer
Parent/Legal Guardian Last Name
*
Your answer
Medical Insurance
*
Yes
No
Medical Insurance Carrier #
Your answer
CIN#:
Your answer
Address:
*
Your answer
City:
*
Your answer
State and Zip:
*
Your answer
Phone:
*
Your answer
Email:
*
Your answer
Relation to
Child or Client
:
*
Parent
Legal Guardian
Suggested Time to Contact: (Select all that apply.)
Morning
Afternoon
Evening
Preferred Language
Your answer
Who assisted you with his form?
*
Nathaniel Fleming
Organization/Company
No One
Unsure
If you have selected
"Organization/Company"
in the question above and know the name of organization or company. Please provide their name below.
Your answer
Is your family in need of any other
Free New York City Funded
forms of assistance? Select all that apply.
Older Adult Care Assistance
Drug and Alcohol Recovery Assistance
Other
Clear selection
If you have selected
"Other"
in the question above. Please provide what you need assistance with?
Your answer
Rate your experience:
1
2
3
4
5
Clear selection
Comments?
Your answer
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