Center Associates - Child Emergency Plan and Authorization to Release/Obtain Information

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Primary Emergency Contact:  Must be 18 years of age or older
Is there a signed release on file for Center Associates to speak to this person? *
In case of an emergency or crisis, these options will be utilized by the child, parent/guardian, or Center Associates staff.
  • Call the emergency contact listed above.
  • Call family, friends, and other individuals who are supports.
  • Call family doctor:
  • If you receive BHIS {in-home) services, contact your provider.
  • Call Center Associates at (641) 752-1585 during business hours: Mondays 8:00 a.m. to 6:00 p.m. Tuesdays through Fridays 8:00 a.m. to 4:30 p.m.
  • After business hours, contact the Center Associates Emergency Line at (641) 752-8467 or Foundation 2 Crisis Hotline
  • (24 hours) 1 (800) 896-2055.
  • Go to the nearest Emergency

Unity Point Hospital/Marshalltown

3 South 4th Avenue Marshalltown, IA 50158

(641) 754-5151

Unity Point Hospital/Marshalltown

3 South 4th Avenue Marshalltown, IA 50158

(641) 754-5151

Hansen Family Hospital
 
920 South Oak Street Iowa Falls, IA 50126
 
(641) 648-4631

Skiff Medical Center

204 North 4th Avenue E Newton, IA 50208

(641) 792-5086

Grinnell Regional Medical Center

21O 4th AvenueGrinnell, IA 50112

(641) 236-7511

Grinnell Regional Medical Center

21O 4th AvenueGrinnell, IA 50112

(641) 236-7511

Utilize community resources/supports:

SATUCI: 752-5421

Crisis Child Care: 752-1730 Salvation Army: 753-5236

Department of Human Services (OHS): 752-6741 Emergency Food Box: 753-0486

Iowa Legal Aid: (319) 235-7008

Access Assault Care Center: 753-4143

MICA: 753-5523

Central Iowa Community Services: 754-6390 OHS Case Management: 844-1510

House of Compassion: 752-5999

If a true emergency, call 911

AUTHORIZATION TO RELEASE/OBTAIN INFORMATION

Mental health information may only be disclosed pursuant to the written authorization of the client or the client’s legal representative or as otherwise provided in Chapter 228, Code of Iowa.  Any unauthorized disclosure of mental health information is unlawful and is subject to civil damages and criminal penalties.  This release is requested for the following purpose(s): (1) To communicate and share information to provide efficient, effective treatment; (2) To establish a basis for determining eligibility for disability or other entitlement programs; (3) To make referrals; and/or (4) To communicate and share information at the request of the client.

This authorization is voluntary and expires 12 months from the date of my signature.  If I choose to cancel this consent prior to the expiration date, I must provide written notification to Center Associates.  If this consent is cancelled, I understand that information may have been released prior to the cancellation, and that action would not be considered a breach of confidentiality.  I also acknowledge that: 1) recipients of this information may possibly re-release the information without proper authorization, and 2) once information is disclosed it may no longer be protected by federal privacy regulations.  I understand that I may review the disclosed information.  Any questions may be directed to the Center’s Release of Information department.

Center Associates does not require completion of this form as a condition of evaluation or treatment.  However, when the provision of services is solely for the purpose of research related treatment or creating information for disclosure to a third party, refusal to sign may result in denial of those services. 

I authorize Center Associates, either verbally or in writing, to release and/or obtain information from:

Release/obtain the following information *
Signature (Electronically signed by) *
clear
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Relationship if not client *