First name: 

Last name: 

Date of Birth:   (month/day/year)

Phone:   (include area code)

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Please read Client Rights and Responsibilities

Please read Joint Notice of Privacy Practices

Please read Family Preservation and Support Services Consent

I hereby acknowledge that I have received and have been given an opportunity to read a copy of Children’s Wisconsin Community Services Joint Notice of Privacy Practices.  I understand that if I have any questions regarding the Notice or my privacy rights, I can contact the Children’s Wisconsin Compliance Officer, Tom Twinem, (9000 West Wisconsin, Milwaukee, WI 53201) at (414) 266-2215.

Date:   (month/day/year)

Please check this box once you acknowledge the copies above

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