Referral & Therapy Form

 
 

Policies and Consent

In order for Cherish to assist you with obtaining therapeutic services, please complete and submit this form. By submitting this form, you acknowledge that you have read these policies and you consent to services and/or referrals from Cherish.

TRAUMA THERAPY PROGRAM - You are being referred as a Cherish client to therapy services. You have participated in a Cherish interview within the last year. - As a Cherish family, you may be eligible for financial assistance for therapy services; if financial assistance is needed, please complete the attached Referral and Financial Assistance Application - Financial assistance is never guaranteed and is based on federal poverty guidelines and current available funding.  - One automatically qualifies for financial assistance if income is at or below 138% federal poverty guideline.  If not below the 138% poverty guideline, please provide proof of need, including proof of income and expenses, which will be reviewed by the clinical advisory board to determine if financial assistance will be provided.   - Understand that your insurance will be billed first, as applicable.  Cherish assistance may cover session costs, co-pays, or costs not covered by your insurance.   - Any financial assistance is provided to specifically address the trauma that involved a Cherish forensic interview.   - If assistance is provided, you will receive $2000 per child in the home seeking services and $1000 per adult seeking trauma related services.  Family sessions will be billed under the primary client.   - Financial assistance by Cherish may not cover the full cost of therapy services.  Once all assistance is utilized, you are responsible for making arrangements with your therapy provider on payment options. - Please abide by your provider’s specific cancellation policy.  Appointments cancelled without proper notice and no shows will not be tolerated.  This does not apply to emergencies or serious illness.   - Cherish will not pay any fees due to not following proper cancellation procedures or for no shows.
Parent/Guardian Name
Parent/Guardian Name
Today's Date *
Today's Date
By checking this box and submitting this form, you acknowledge that you have read these policies and you consent to services and/or referrals from Cherish. *
Name of Child *
Name of Child
Legal Guardian
Legal Guardian
Additional Legal Guardian
Additional Legal Guardian
Phone Number *
Phone Number
Address *
Address
May we leave a voice message if no answer *
Is Financial Assistance needed in order to obtain services *
Do you fall at or below the 138% poverty guideline? *
If not, you must provide proof of need (proof of income and expenses. Persons in Household (Col. 1)—FPL100% (Col. 2)—FPL138% (Col. 3) 1 $12,060 $16,642 2 $16,240 $22,411 3 $20,420 $28,179 4 $24,600 $33,948 5 $28,780 $39,716 6 $32,960 $45,484 7 $37,140 $51,253 8 $41,320 $57,021 Add $4,160 for each additional person if household has more than 8 people
Is there a Divorce Decree or other Court Order in place affecting the child? *
Date seen at Cherish
Date seen at Cherish
DCS Contact
DCS Contact
DCS Contact Phone Number
DCS Contact Phone Number
Law Enforcement Contact
Law Enforcement Contact
Law Enforcement Contact Phone Number
Law Enforcement Contact Phone Number
Voluntary Consent *
Name of Individual Completing Form *
Name of Individual Completing Form
I understand:
- That Cherish has an obligation to keep my personal information, identifying information, and my records confidential.  I also understand my information will be shared among the Cherish Multidisciplinary Team in order to provide effective case management and that I can choose to allow Cherish to release some of my personal information to certain individuals or agencies. - That I do not have to complete a release form. I do not have to allow Cherish to share my information. Completing a release form is completely voluntary. - That releasing information about me could give another agency or person information about my location and would confirm that I have been receiving services from Cherish. - The risks and benefits of releasing the confidential information to the above organization or person. - That a limited release of information can potentially open up access by others to all of my confidential information held by Cherish. - The specific information that I want to be released and how it will be shared. I understand email is not confidential. - That Cherish and I may not be able to control what happens to my information once it has been released and that the agency or person getting my information may be required by law or practice to share with others. - That this release is valid for a period not to exceed one year from date below. If additional time is necessary to meet the purpose of this release, I will need to sign a new release form. - That this release is valid when I check this box and complete this form and that I may withdraw my consent to this release at any time either verbally or in writing.
Date Completed *
Date Completed
Voluntary Consent *