Coordinated Services Team Initiative (Cst) Page 3

Consent for Referral and Participation

I give my consent to ____________________________________ to refer my child and family

members as identified to the _____________ Coordinated Services Team (CST) initiative. I

agree to participate in the team process and to play an active role in the assessment and case

planning processes.

I understand that I will be asked to identify the service providers working with my family and to

sign release forms authorizing the exchange of information. I realize that as long as our family

is involved in CST, it will be necessary for service providers to routinely review and share

information.

____________________________________________ Date ______________

Signature of Individual Authorizing Referral

____________________________________________ Date ______________

Second Authorization/Witness Signature

Module 2

Page 20

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Parent category: Business