PGM Family Applications

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Onboarding Application for Services

Email *

Perfect Generation Ministries, Inc. (PGM Family) Est. 2021

Our Mission is to assist with stabilizing families impacted by Gun Violence, Mental Health and Health Challenges through Nurse Case Management services and a pathway for our youth and their families to develop life skills and sustainability.

Full Name: *

5 points

Date of Birth: *

5 points

YYYY

Address with County and State *

5 points

Phone Number *

5 points

Have you experienced gun violence? *

5 points

Yes

Do you have insurance? *

5 points

Yes

Provide your Insurance Carrier name and Number: *

5 points

How many individuals living in your home? Please list EVERYONE with their age and date of Birth. If not completed properly. We will not be able to assist. *

5 points

Tell us more about your situation? *

5 points

Acknowledgement and Consent:

The ______________________Family has been enrolled in our organization (Perfect Generation Ministries, Inc.) for various services. The ___________________ Family has given our organization permission to communicate on their behalf and to advocate for services that will benefit the family and improve their quality of life. This letter is a legal binding agreement to allow Staff at Perfect Generation Ministries, Inc. (a nonprofit 501(C)3) to communicate with the following companies and or individuals: at Mental Healthcare professionals agencies; Primary Care Provider/s and Specialists; family members with limitations per the ___________________family instructions; Case Managers from any other agencies client/s are receiving services and any organizations/persons deemed appropriate for the care of the family future needs. The _______________________ family has given permission to communicate in the following way: Video/Photography/Texting

/emailing/phone calls/Websites/ any form of communication will be allowed with the protection of HIPAA disclaimer. Each Family member of the _________________________ household is listed below as a reference. PGM is in agreement to advocate in the best interest of the client and the client only. The family give permission for Perfect Generation Ministries, Inc to use photos/videos as deemed needed for PGM events or activities and more. This letter of notice will start immediately and will remain effective until the family is no longer enrolled in PGM and will remain on file as long as Federal and State Regulations require. All photos and videos taken will be the property of Perfect Generation Ministries, Inc. If you have any concerns or questions, please do not hesitate to contact us directly at 443-583-8909.

Upon completion of this online application you are consenting electronically to all the above and below statements in this application. All individuals will not hold Perfect Generation Ministries, Inc. (PGM Family) at fault for anything that resulted from the client lack of contributions. Furthermore, this nonprofit has the right to discharge anyone at anytime immediately.

Sign by Typing Your Name and Date: *

5 points

Privacy Act Policy and HIPPA Law, Code of Conduct, Harassment of Any Kind, Volunteer Agreement for all participants, and DEI Policies will be upholded at all times please Type your Name in Full or Application will not be Accepted.

I, ______________________, give permission to Perfect Generation Ministries, Inc. to discuss our household needs and Healthcare needs at this time (Entire Household Regardless of age). And, use our pictures and videos on any social media platform.

Policies that will be provided during your intake/Onboarding Process(Must be signed prior to receiving any services, if not signed within (2) weeks notice: Immediate Termination of Program Assistance with no re-entering):

____HIPAA Disclaimer/Privacy Act Policy

____Organization Code of Conduct

____Client Responsibilities/Rights

____Program Responsibilities/Rights

____Volunteer Process and opportunities

____Disclaimer of Insurance Involvements

____Release of Liabilities agreement

____ Grounds for Termination of Services

____Policy for Mandated Programs With Multiple ____Agencies and/or Businesses

____Participation Agreement

____To Download Slack and use this to Communicate Agreement

Perfect Generation Ministries, Inc. (PGM Family) Disclaimer

I agree and understand that Perfect Generation Ministries, Inc. (PGM Family) will not diagnose or attempt to cure any diseases of any kind and the Nurse Case Management Services is a mandatory service in this program.

I further understand that I should continue under the care of my physician and not discontinue any medication without the advice of my doctor while a participant of the perfect Generation Ministries, Inc. (PGM Family)

I acknowledge that my participation in this program will require me to volunteer my time back to PGM Family and I accept full responsibility for the management of my own health care including my mental health, goals/ Care Plan.

I acknowledge to advise my doctors/mental health counselor and will continue to be monitored by my doctor/mental health counselor throughout the duration of my involvement in Perfect Generation Ministries, Inc. (PGM Family)

I understand that Perfect Generation Ministries, Inc. (PGM Family) is not designed to be a substitute for any medication and/or mental health counseling which may have been prescribed by a physician or would be prescribed if I were to seek medical attention including mental health services.

I acknowledge that Perfect Generation Ministries, Inc. (PGM Family) does not provide a medical diagnosis, prognosis, or substitute for medication or medical advice or mental health counseling but provide resources.

I acknowledge that My behavior while participating in PGM Family is solely my responsibility to conduct myself as a upstanding manner and in a non-vulgar way.

I further agree that Perfect Generation Ministries, Inc. (PGM Family) is not responsible for any of my health care needs and mental health services, in fact, I am responsible.

I have read the above and agree to abide by the conditions described herein.

I further understand that my acceptance and continuation in Perfect Generation Ministries, Inc. (PGM Family) is conditional upon my written acceptance of the conditions set forth.

Furthermore, if at anytime I fail to abide by the above conditions, my participation is subject to termination from the program.

Respectfully,

Dr. Katrina M. Fowlkes,BSN, RN CM/DN

Chief Executive Officer (CEO)

Stay Prayed Up

Founder

Please sign by Typing your FULL NAME and Date below:

5 points

A copy of your responses will be emailed to the address you provided.

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