620 Dakota Street Crystal Lake, IL 60012 Client Intake & Information Release/Exchange Form Start HereIf you are a family member supporting a loved one with a mental health condition and are seeking services through NAMI MC- please list yourself as the client. Your loved one needing services will need to fill out a separate Client Intake. Name of Client: (First & Last Name)* Email* Date of Birth:* MM slash DD slash YYYY Address:* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*What County do you live in?* Are you or someone you know in crisis currently?*YesNoAre you seeking One-on-One Support for yourself as an individual with a mental health condition or as a family member supporting a loved one?*MyselfFamily MemberObservation of self or loved one:Respond to the following statements below, for the last two weeks, how often you or your loved one have been bothered by the following problems.Feeling nervous, anxious or on edge.*Not at AllSeveral DaysNearly Every DayNot being able to stop or control worrying.*Not at AllSeveral DaysNearly Every DayLittle interest or pleasure in doing things.*Not at AllSeveral DaysNearly Every DayFeeling down, depressed or hopeless.*Not at AllSeveral DaysNearly Every DayMHB AuthorizationI hereby authorize NAMI McHenry County to release the information given above and the reason for which I am seeking services to the McHenry County Mental Health Board (MHB). I understand the McHenry County Mental Health Board is a funding source for the program, in order for services to be offered at no cost to clients. This authorization becomes effective on the Electronic Signed Date below and extends 1-year out.Authorization for McHenry County Mental Health Board* I understand checking this box constitutes a legal signature for myself or my childConsent for self and/or childRelease / Exchange of InformationI hereby authorize NAMI McHenry County to release the information given above and/or information provided pertaining to my participation in NAMI programs to the organization(s) listed below. I hereby authorize the organization(s) listed below to provide information regarding my treatment to NAMI McHenry County to assist with all around care. This authorization becomes effective on the Electronic Signed Date below and extends 1-year out.Nature of information to be released: List Names of Organizations to contact: List all organization to release/exchange information.Understanding of ConsentI understand that I may revoke this consent at any time (MUST be in writing). I understand that if I choose to revoke this consent, this will be effective when this form is received by NAMI McHenry County. I understand that I have the right to inspect and copy the information to be disclosed. The released information may not be re-released to any other person or organization without consent of the client.Client and/or Guardian Consent* I understand checking this box constitutes a legal signature for myself or my childConsent for self and/or childCommunity Collaboration or School AdvocacyAdditional General Releases to be used for Community Collaboration or School Advocacy being submitted by parents of youth 12 years, will need the youth's signature as well as the parent seeking services/resources in order for the release to be valid. Student 12-17 MUST sign.Youth Consent (12-17 years of age) I understand checking this box constitutes a legal signature for myselfConsent for youth ages 12-17Electronic Signed Date* MM slash DD slash YYYY Notice to Receiving PartyNotice to Receiving Agency/Facility/Staff Person: Under the provisions of the Illinois Mental Health and Developmental Disabilities Act. (Ill.Rev.Stat, Ch 911/2, par 801 et seq.) 740 ILCS 110/1 et seq.) you may not disclose any of this information unless the person who consented to this disclosure specifically consents to such re-disclosure. Under Federal act of July 1, 1975, Confidentiality of Alcohol and Drug Abuse Patient Records, no such records, nor information from such records may be further disclosed without specific authorization for such re-disclosure.
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