Welcome Parents!

This section of our website is designed specifically for you. We’re thrilled that you’ve chosen Mentoring, LLC for your respite services, and we’re here to help you connect with the ideal respite provider. We’ve compiled several forms that need to be filled out at the beginning of our services, along with others that will require regular updates. We’ve also enlisted the help of referring parties to you through the referral process. If you have any questions, please feel free reach out to us; we’re here to help. Please fill the "Parent Intake Form" and the "Release of Information Form," while your Referring Source will handle the "Referral Form found under the "Referral Source" section. After we receive these forms, we’ll get in touch to schedule an initial screening to discuss your needs and learn more about you and your family. Once we all agree that Mentoring Matters will provide respite services, additional forms will need to be completed, including the "Medication Form," "Consent to Treat," "Informed Consent," and "Publicity."

Parent Intake Form

Child Information:

Name:

Date of Birth:

Month

Day

Year

Address

Age:

Sex:

Medical Information:

Medical Needs:

Allergic Reactions:

Specific Medical Conditions:

Medications (if applicable): List medication names here and complete a Medication Form.

Behavioral Information:

Does your child need help with hygiene, if so, please describe:

Great Likes and Dislikes

Triggers:

Favorite Foods:

Foods to Avoid:

Family Dynamics:

Lives with:

Other information:

School Information:

School Name:

Grade:

Teacher's Name:

School Contact Number:

Emergency Contacts:

Primary Emergency Contact Name:

Relationship to Child:

Phone Number:

Secondary Emergency Contact Name:

Relationship to Child:

Phone Number:

Parent/Guardian Information:

Name:

Relationship to Child:

Cultural or Religious Considerations:

Hobbies or Interests:

Communication Preferences:

Preferred Method of Communication:

Best Time to Contact:

Additional Notes or Comments:

Parent/Guardian Signature:

By typing my name below, I agree that this electronic signature is valid and binding. I confirm that the information provided is accurate and up-to-date.

Parent/Guardian Name:

Date:

Release of Information Form

Child Information:

Name:

Date of Birth:

Month

Day

Year

Parent/Guardian Information:

Name:

Phone Number:

Social Worker Information:

Name:

Phone Number:

Email Address:

Agency/Organization:

Information to be Released:

I authorize the release of the following information regarding the above-named child:

Medical Records

Educational Records

Psychological Evaluations

Other:

Purpose of Release: The information will be used for the following purpose(s):

Treatment/Continuing Care

Educational Planning

Legal Proceedings

Other:

Recipient Information: (The information may be released to:)

Name:

Organization:

Phone Number:

Email Address:

Duration of Release: (This authorization is valid for:)

Specific Time Period: From date this form is signed until respite services end (leave dates below blank).

Or if a specific time period of time is requested, complete the dates below:

From _

To _

Event: Any information related to respite care services and/or establishing services.

Statements of Rights

I understand that I have the right to revoke this authorization at any time by providing written notice to the authorized person or organization. I understand that revocation will not affect any actions taken before the receipt of the revocation. I understand that information disclosed under this authorization may be subject to re-disclosure by the recipient and may no longer be protected by privacy regulations.

Parent/Guardian Signature:

By typing my name below, I agree that this electronic signature is valid and binding. I confirm that the information provided is accurate and up-to-date.

Parent/Guardian Name:

Date:

Medication Form

To complete the Child's Medication Form, fill in your child's name, date of birth, and your contact information. List each medication with its name, dosage, frequency, directions for use, start date, and end date. Include any additional notes such as allergies or side effects. Review the form for accuracy and update it whenever there's a change in medication. Email the completed form to (insert email address) and print a copy for your records.

Child's Name:

Date of Birth:

Month

Day

Year

Parent/Guardian Name:

Contact Number:

Medications:

Medication Name:

Dosage:

Frequency:

Directions for Use:

Start Date:

End Date:

Additional Notes:

Important Notice to Parents/Guardians

Please complete this form every time there is a change in your child's medication. This ensures that we have the most up-to-date information to provide the best care for your child. Once completed, please email the form to [insert email address] and print a copy for your records.

Parent/Guardian Signature:

By typing my name below, I agree that this electronic signature is valid and binding. I confirm that the information provided is accurate and up-to-date.

Parent/Guardian Name:

Date:

Consent to Treat Form

Child Information:

Name

Date of Birth:

Month

Day

Year

Parent / Guardian Information:

Name:

Phone Number:

Email Address:

Social Worker Information:

Name:

Phone Number:

Email Address:

Agency / Organization:

Emergency Contacts:

Primary Emergency Contact Name:

Relationship to Child:

Phone Number:

Secondary Emergency Contact Name:

Relationship to Child:

Phone Number:

Specific Medical Conditions:

Please list any specific medical conditions, allergies, or special needs that the child has:

Consent to Treatment

I, the undersigned, hereby consent to the following treatments for my child:

Medical Treatment:

Routine medical examinations and treatments

Administration of medications as prescribed

Diagnostic tests (e.g., blood tests, X-rays)

Emergency medical care

Dental Treatment:

Routine dental examinations and cleanings

Dental treatments and procedures as necessary

Emergency dental care

Emergency Treatment:

Emergency medical and dental care as needed

Transportation to the nearest hospital or emergency facility if required

I understand that these treatments may involve certain risks and that all efforts will be made to contact me or the emergency contacts listed above before any treatment is administered. I acknowledge that I have been informed of these risks and consent to my child's participation in the necessary treatments.

Duration of Consent: (This consent is valid for:)

Specific Time Period:

From:

To:

Event: While child is in respite care and/or transporting to/from

Parent/Guardian Signature

By typing my name below, I agree that this electronic signature is valid and binding. I confirm that the information provided is accurate and up-to-date.

Parent / Guardian Name:

Date:

Note: Please attach any additional documentation as required.

Parent / Guardian Permission Form

Accomplish Form Here

Informed Consent /

Indemnification Agreement

Child Information:

Name:

Date of Birth:

Month

Day

Year

Parent/Guardian Information:

Name:

Phone Number:

Email Address:

Referring Party Information (e.g. Case Manager, Social Worker, etc.):

Name:

Position Title:

Phone Number:

Email Address:

Agency / Organization:

Emergency Contacts:

Primary Emergency Contact Name:

Relationship to Child:

Phone Number:

Secondary Emergency Contact Name:

Relationship to Child:

Phone Number:

Indemnification and Release of Liability

I, the undersigned, hereby agree to indemnify and hold harmless Mentoring Matters, LLC, its employees, agents, and volunteers from any and all claims, damages, losses, and expenses, including attorney's fees, arising out of or resulting from the participation of my child in respite services, except for those claims arising from the gross negligence or willful misconduct of Mentoring Matters, LLC.

I understand that respite services involve certain risks, including but not limited to physical activities, transportation, and interactions with other children and staff. I acknowledge that I have been informed of these risks and consent to my child's participation in respite services.

Consent to Treatment: I consent to the provision of respite services for my child, including any necessary medical treatment in the event of an emergency. I understand that every effort will be made to contact me, or the emergency contacts listed above before any treatment is administered.

Parent/Guardian Signature:

By typing my name below, I agree that this electronic signature is valid and binding. I confirm that the information provided is accurate and up-to-date.

Parent/Guardian Name:

Date:

Note: Please attach a release of information form.

Publicity Agreement

This Publicity Agreement ("Agreement") is made and entered into as of

Date

by and between Mentoring Matters, LLC ("Organization") and

[Name of Parent/Guardian]

Parent/Guardian of [child’s name]

1. Purpose The purpose of this Agreement is to obtain consent from the Parent/Guardian for the Organization to take and share photographs and videos of the Child with other parents involved in the Organization's programs. These images will not be shared on any websites or public platforms, ensuring the privacy of the Child.

2. Consent The Parent/Guardian hereby grants permission to the Organization to take photographs and videos of the Child during the Organization's activities and to share these photographs with other parents involved in the Organization's programs.

3. Privacy Assurance The Organization agrees that the photographs of the Child will not be shared on any websites, social media platforms, or any other public forums. The photographs and videos will only be shared privately with other parents involved in the Organization's programs.

4. Duration This Agreement shall remain in effect for the duration of the Child's participation in the Organization's programs unless revoked in writing by the Parent/Guardian.

5. Revocation of Consent The Parent/Guardian may revoke this consent at any time by providing written notice to the Organization. Upon receipt of such notice, the Organization will cease to take and share photographs of the Child.

6. Governing Law This Agreement shall be governed by and construed in accordance with the laws of the state of Wisconsin.

7. Acknowledgment The Parent/Guardian acknowledges that they have read and understood this Agreement and agree to its terms.

Signatures:

By typing my name below, I agree that this electronic signature is valid and binding. I confirm that the information provided is accurate and up-to-date.

Parent/Guardian Name:

Date:

By typing my name below, I agree that this electronic signature is valid and binding. I confirm that the information provided is accurate and up-to-date.

Organization Representative Signature:

Date: