PCHC Team Agreement Form (TAF)

Individual Demographics


Supports Coordinator

Provider Agency or Family Member  (If the Individual lives at the agency please enter the agency contact's information. If the Individual lives at home please enter the family member information.)

Contact Person for this Request (SC, Provider Agency or Family Member)

Provider Agency Nurse

Has Agency Nurse been notified regarding situation and PCHC involvement?

For what Health Care Issue(s) are you requesting PCHC's assistance?

All PCHC reviews are undertaken in the context of the whole person, encompassing multiple healthcare needs including: physical health, social-emotional well-being, behavioral health and environmental concerns.  *

Report Recipients  (Please complete information below for all persons requesting a PCHC report.)

Supports Coordinator Report Recipient:

Agency/Family Report Recipient (#1):

Agency/Family Report Recipient (#2):

Administrative Entity Report Recipient:

Who will be responsible for dissemination of this request information?
(The completed Team Agreement Form will be emailed to the person shown below.)

Who is the person submitting this request?

Agreement (Please enter the person requesting/requiring assistance, team/family members and other involved parties such as Behavior Specialist or Psychologist.)

Consent to Agreement

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