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Step One

Greene County Family and Children First
Disclaimer: Information submitted on this form will be sent via email. If you would prefer to provide information such as Social Security numbers, driver's license numbers, bank account information, routing numbers, medical information, passport numbers, passwords or other sensitive information in another form, please indicate your intention on the form or by emailing melissa.baughn@greenecountyohio.gov
New Client Form
Please complete this form in it's entirety and attach any supplemental documents before submitting. For questions, please contact Melissa Baughn at melissa.baughn@greenecountyohio.gov or (937) 562-5607.
Youth First Name*
Youth Last Name*
Address1*
Address2
City*
State*
Zip*
Parent/Guardian First & Last Name *
Home Phone Number *
Mobile Phone Number *
Form Completed By (Name)*
Relationship to Youth*
Date*
Insurance Information
PLEASE PROVIDE A COPY OF YOUTH'S SOCIAL SECURITY AND INSURANCE CARDS
Social Security Number
Social Security Card Image
Medical Insurance Provider*
Policy No.
Policy Holder Name*
Policy Holder Date of Birth*
Policy Holder Date of Birth
Insurance Card Image
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Step Three

CONSENT FOR RELEASE OF INFORMATION
Name of Youth*
Youth's Date of Birth*
Youth's Date of Birth
Social Security Number
Parent/Guardian Signature*
By typing your name in this field, you indicate permission to share relevant information with the agencies selected below. This may include identifying, case-related, medical, psychiatric, educational, drug/alcohol abuse or financial information for the purpose of securing, coordinating, planning or providing services for the above-named person.
Date Signed*
Date Signed
Please initial the box below all agencies from which you are currently or have previously received services, and any known future agencies. ** Initialing indicates permission for Greene County Family and Children First to exchange relevant information with said agency. **
CASA
Council on Rural Services
Greene Academy
Greene County Board of Developmental Disabilities
Greene County Children Services
Greene County Combined Health District
Greene County Department of Job and Family Services
Greene County ESC and LC
Greene County Family and Children First*
Greene County Juvenile Court
Help Me Grow
Mental Health and Recovery Board of Greene County
Miami Valley Juvenile Rehabilitation Center
Parent Advocacy Connection
School District
Please initial & Write Name of District
TCN Behavioral Health / Family Solutions
Additional Authorized Service Providers
Providing the name of additional service providers below indicates permission for Greene County Family and Children to exchange information with said provider.
Service Provider Name
Service Provider Name
Service Provider Name
Service Provider Name
Revocation of Authorization of Release of Information
This information will remain in effect for 365 days after the date signed unless I specify an earlier expiration date indicated below. The revocation does not include information that has been shared between the time I gave permission until the time it was revoked. I understand that my records are protected under federal regulations governing confidentiality of alcohol and drug abuse. Federal regulations 42 CFR Part 2 prohibits you from making further disclosure of it without my specific written consent. Federal rules restrict any use of information to criminally investigate or prosecute for any alcohol or drug abuse client.
If l determine I would like to revoke these privileges at any time, I can contact Greene County Family and Children First and will be provided with a Revocation of Authorization of Release of Information form to complete.
** Only complete this section if you would like permission to terminate in less than 365 days. **
Revised Date of Expiration
Revised Date of Expiration
Only complete if less than 365 days from date of signature.
Signature of Person Age 16 or Older
Typing a name in this field indicates understanding and agreement with the paragraph above.
Dispute Resolution Policies and Procedures
The Dispute Resolution Policies and Procedures have been made available for download on the Greene County Family and Children First Website. Additionally, upon request, can be provided by email or mail.
Filling in a name below indicates I understand how to obtain a copy of the Dispute Resolution Policies and Procedures.
Please contact the Family Stability Coordinator at 937.562.5600 with any questions regarding or to obtain a copy of the Dispute Resolution Policies and Procedures
Parent/Guardian Name*
Youth's Name*
Date*
Date
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Step Four

Agreement For Services and Statement of Accountability
Youth First Name*
Youth Last Name*
I/We are requesting High-Fidelity Wraparound Services through the Greene County Family and Children First service coordination mechanism. Information describing service coordination has been made available to me/us, and I/We understand it is a voluntary program.
Participating in Service Coordination means I/We agree to:
- participate in an initial referral and planning process with a High-Fidelity Wraparound team of formal and informal support providers.
- participate in on-going team reviews and be accountable for the family's progress within service coordination. The frequency of team reviews will be determined by my team.
- participate in initial and periodic family questionnaires.
The Service Coordinator and/or Family and Children First staff agree to:
- provide open and honest communication with the family.
- empower the family to make their own choices.
- value all communication with the family as personal and confidential, sharing information with entities/individuals only with valid and current signed release(s) of information or as mandated by law.
- monitor progress and needs.
- arrange for regular High-Fidelity Wraparound meetings as recommended by the team.
- whenever possible, attend meetings or reviews as requested by the family (i.e. IEP meetings, court hearings, family team meetings).
Parent/Guardian Signature 1*
Completing this field indicates understanding and agreement with above statements.
Parent/Guardian Signature 2*
Completing this field indicates understanding and agreement with above statements.
Date*
Date
Service Coordinator Signature
Please leave blank. This field will be completed by Family and Children First.
Date
Date
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Step Five

Family-Centered Services and Support Funding
Name of Youth*
Date of Birth*
Date of Birth
Family-Centered Services and Supports money is a combination of federal child welfare dollars and state general revenue funds. This funding is limited to youth ag 0 to 21 whose family has an open plan or High-Fidelity Wraparound service plan. The family must meet monthly with the High-Fidelity Wraparound team on identifying family and youth needs. The service must be written into the service coordination plan and be identified as a part of the plan to strengthen the family. Funds are temporary and limited due to community needs. Funds are restricted to being used for community-based services which promote the stability and well-being of children and families. They cannot be used for the following:
- Services to support a child in an out-of-home placement setting
- Court-related expenses
- Clinical interventions
- Medical services and equipment
- Food, clothing, shelter, utilities or household expenses
- Classroom instruction including, but not limited to, tutoring, summer school or credit recovery
- Family- and work-related child care
Respite services are funded only when part of the wraparound plan and pre-approved by the service coordinator prior to receiving the service. Respite invoices must be turned in by the 15th of the month following service.
When turning in an invoice for payment, bills must be on the organization's letterhead with address, type of service provided, client name, service start date, service end date and the organization's Federal Tax ID (EIN) Number. All invoices must be pre-approved by the service coordinator prior to being submitted for payment.
** Please note, we make every effort to process invoices in 30 days. This may be delayed if invoices are incomplete or when grant funds from the state are not received in a timely manner. **
Parent/Guardian Signature*
Completion of this field indicates an understanding and acceptance of the Family-Centered Services and Support Funding policy.
Date*
Date
Service Coordinator
Please leave blank. This field will be completed by Family and Children First.
Date
Date
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Step Six

Family Strengths and Needs Assessment
Name of Youth*
Date of Birth*
Date of Birth
What does your family like to do together?
What are the best things about each of your children?
What supports are in place for your family (i.e. counselors, teachers, friends, religious figures ...)?
Does your family have adequate resources for housing, clothing and nutrition?
If you could meet one need or goal over the next year, what would it be?

Leave This Blank:

1. Receive an email copy of this form.
Email address

This field is not part of the form submission.
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