Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.CREDIBLE HEALTH SOLUTIONS Mental Health Targeted Case Management (MHTCM) Two-Phase Client Intake Packet Phone: 281-339-7665 | Email: Veidusuyi@CredibleHS.com PHASE 2: POST-VERIFICATION & CLINICAL DOCUMENTATION (To be completed after insurance verification & initial assessment) Client Rights & Responsibilities Acknowledgment *I have received, reviewed, and understand my rights and responsibilities as a client.Signature * Clear Signature Date *Staff Signature Automatic Date Form Date Grievance Policy Acknowledgment *I acknowledge that I have been informed of Credible Health Solutions’ grievance procedures and know how to file a complaint.Client/Guardian Signature * Clear Signature Date *Emergency Contact & Crisis PlanEmergency Contact Name: *Phone *Preferred Hospital (if any):Safety Plan Summary (if applicable):Advance Directives (For Adults Only) *I have received information regarding advance directives.I have completed advance directives.I decline to complete advance directives at this time.Client/Guardian Signature: * Clear Signature Date *Cultural and Linguistic Needs AssessmentPreferred Language: *Interpreter NeededCultural or Religious Practices to Consider in Treatment:Audio/Video Recording Consent (If applicable) *I consent to audio/video recordings for supervision/training.I do not consent to any recordings.Client/Guardian Signature: * Clear Signature DateSubmit
