Roots Informed Consents/ISP/VA - Client Self-Service Client InformationClient Name* First Middle Last Client Date of Birth* Month Day Year Client Email Initial Service PlanDo you want to include an initial service plan? Yes No Service Initiation Date MM slash DD slash YYYY Immediate Health Concerns?* Yes No Please describe the health concerns and a plan to address them*Immediate Safety Concerns?* Yes No Please describe the safety concerns and a plan to address themIdentify the treatment needs of the client to be addressed during the time between the day of service initiation and development of the treatment plan*Vulnerable Adult DeterminationDo you want to include a vulnerable adult determination? Yes No 1. Does the client have a physical or mental infirmity or other physical, mental, or emotional dysfunction?* Yes No Proceed to the next question.2. Does the client’s physical or mental infirmity or other physical, mental, or emotional dysfunction, impair the client’s ability to provide adequately for the client’s own care without assistance, including the provision of food, shelter, clothing, health care, or supervision.* Yes No Proceed to the next question.3. Does the client’s dysfunction or infirmity and the need for assistance impair the client’s ability to protect the client from maltreatment.* Yes No Client IS a vulnerable adult. Please choose from options 2 or 3 below.Client is NOT a vulnerable adult. Please choose option 1 below.Determination Status* Client is determined NOT to be a vulnerable adult Client is determined to be a vulnerable adult but specific needs are adequately addressed by program abuse prevention plan. Client is determined to be a vulnerable adult and needs an Individual Abuse Prevention Plan Individual Abuse Prevention Plan* Δ
