Please fill in the questions below:
Please choose the answer that best describes how you manage your diabetes.
How confident are you?
This form should be completed after consumables have been distributed to the participant.
The following questions will help to make referrals in keeping with your personal beliefs.
The following question will help to determine if information on health-disparity issues might be of importance to you or your family.
Please print and complete all sections on both pages.
Please enter the amount for the following incomes.
Please enter the amount of each of the following expenses.
Authorization for the use and disclosure of personal information acquired through The Jesse Tree
Application, screenings, and interviews and that is entered into the electronic database.
By signing this Authorization Form, I understand that I am giving my authorization to agents accessing the electronic database to use and/or disclose any data entered into the electronic database including any protected health information as described in more detail in the paragraphs below to any other user of the electronic database or any other agency to which I am referred for assistance.
I acknowledge that I have been shown a list of the agencies that currently have access to this information. Iunderstand the agencies may be added.
Protected Health Information includes but is not limited to the following types of information:
Name, Address, Phone number, Gender, Date of Birth and/or age, City and State of Birth, Financial Data, Social Security Number,Driver’s License Number, Veteran ID Number, Alien Resident ID Number, Alien Resident ID Number, Names of household members or relatives, their date of birth or age, social security number gender Medical conditions including conditions such as:
(1) Acquired immunodeficiency syndrome (“AIDS”) or(2) Human immunodeficiency virus (“HIV) (3) Drug and or alcohol abuse(4) Mental or behavioral health or psychiatric care
Results from screenings concerning my health, race, religion
Notes made by agents based on interviews conducted by them especially related to health issuesI understand that the information collected about me maybe used to refer me for Treatment, Payment, orOperations related actions.
I understand that the information collected about me maybe used for research purposes and the results of this research may be published. In the event research results are published, no personally identifying data will be included in the published materials.I understand that the information collected about me maybe used to apply for grants or to solicit donations from the community. In the even data is used in this manner, no personally identifying data will be included in the published information.I understand that I may request a copy of data held in the electronic database about me. I understand that I May be charged a modest fee for copying/printing this information.I understand that if I disagree with data held about me, I may make a request to have the information modified. These requests should be directed to The Jesse Tree, P.O. Box 575, Galveston, TX 77553. I further understand that The Jesse Tree, at its sole discretion will determine whether or not to make the modification and that the original information will remain with attached notes agreeing to the requested changes.
I understand that I can revoke this authorization at any time by completing and submitting the proper form to The JesseTree, P.O. Box 575, Galveston, TX 77553 or in person.
The Enrollment Portfolio is a Checklist for Adherence Planning
In order to apply for assistance many times you will need to provide proof of employment and income verification. Some of the documents you may need are check stubs, statements of earnings, or if at a new job, you will need the hire date and the date of the first paycheck.
Examples of proof: Letter from friends or relatives who assist you, utility bill in your name, Rent statement/ Lease agreement, property deeds, or Mortgage company name , phone number and loan verification.
This Adherence Plan form is used in conjunction with all Jesse Tree Screening forms, including the Universal Applicationpacket, on-line case management application assessment and subsequent assignment of Triage Levels. It represents anagreement between yourself and The Jesse Tree to assist you in moving your life forward in the direction of genuine wellbeing.
Once you have agreed to participate in the screening and assessment process and have signed the corresponding documents in the The Jesse Tree Application packet, the person with whom you are working may have several suggestions on where and how you can find social services, medical care and ministerial assistance. In return, we require your willingness and your action to keep appointments and follow-up on these opportunities. Your life is precious – treat it accordingly.
The agreement is designed to promote dignity and quality service for and from everyone involved.
Adherence Plan means to follow closely, to carry out or to follow through with something. To help you adhere to the planworked out between you and your Resource Coordinator/Case Manager, The Jesse Tree has established four Triage Levels to help prioritize your needs and responsibilities:
Level 1 -- Indicates an urgent situation of a one-time nature. The problem can be easily verified and resources can beeasily located to solve the problem immediately. Once solved, the problem is not expected to occur again, and stability isrestored. The case can be closed.
Level 2 -- Indicates multiple problems have existed for several weeks, months or longer. In some cases, complicatedproblems have existed for over one year and are chronic in nature. The range of problems present at this level may includechronic medical conditions, mental health or substance abuse problems, and lack of education or job training. Although the problems cannot be solved in one day, they are manageable and relative stability toward successful, long-term treatment can be achieved in several weeks or months. You will keep appointments and show strong determination to solve these problems.
Level 3 -- Indicates a Level 2 assessment; however, after your initial assessment appointment, you have missed 50% ofall follow-up appointments in your service agreement planning and seem to focus on immediate needs rather than long-term solutions. Therefore, you must complete at least one major step in the planning process in order to be allowed to continue working with your Resource Coordinator/Case Manager.
Examples of major steps include but are not limited to:- Keeping an appointment or enrolling in a program.- Consistently attending classes, such as Diabetes or Chronic Conditions- Management Classes, Substance Abuse support groups, etc.
Upon verification of completion of major step to your Resource Coordinator/Case Manager, your Service Agreement Planning will revert to Level 2 status and you may proceed with regular appointments. (Independent verification of step completion is required.)
Level 4 -- Indicates that an incident report is on file for client non-compliance with Level 3 indications within (period oftime, like one year – how long to we want to give the Level 3s to cooperate?) or one or more of the following reasons:
• Use of vulgar, hostile or threatening language• Violent behavior• Incarceration• HELP Loan default
As a result, your communication with TJT will be limited to phone communication with the assigned case supervisor untilfurther notice. You will not be allowed on premise or access to any of TJT support services, apart from phone support, until your case has been reassigned to Level 3 status.
It is the aim of this agreement to support the completion of your plan for well-being. The more steps taken to accomplish the Service Agreement Plan, the sooner your case will resolve and the quicker you will achieve stability in your life. Yoursignature below indicates that you agree to the terms of this Service Agreement Planning process.
Reflects initial request (from screening) and response.
Reflects other potential resources/services/possible enrollments
Reflects enrollments/next steps/goals/referral form(s)
Reflects significant progress/self-motivated planning/outcome measurements
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