ACS INTAKE PACKET

Welcome to Auspicious Community Service (ACS)

Auspicious Community Service (ACS) provides Mental Health Targeted Case Management (MHTCM) and Skills Training services for children, adolescents, and adults. Our services focus on skill-building, care coordination, and linkage to community resources that support daily functioning and long-term stability.

Important Information (Applies to All Clients):

• ACS provides case management and skills training only (not therapy)
• Services are Medicaid-funded for eligible individuals
• There is no out-of-pocket cost for covered services
• Services may be provided in the home, school, community, or via telehealth

I voluntarily consent to receive Mental Health Targeted Case Management (MHTCM) and/or Skills Training services from Auspicious Community Service.
I understand that:
• Services are voluntary and may be withdrawn at any time
• Services focus on skill-building, coordination, and support
• Services are not psychotherapy or counseling

I consent to receive services via telehealth when appropriate and understand my rights regarding privacy, confidentiality, and the option to refuse telehealth services.

I acknowledge receipt of the Notice of Privacy Practices and understand how my protected health information may be used and disclosed.

I authorize Auspicious Community Service to exchange information with the following (check all that apply)

I acknowledge that I have received information regarding:

• Client Rights & Responsibilities
• How to file a grievance or appeal
• Crisis response procedures and emergency contacts