Intake Forms

Intake Forms & Privacy Statement

Please thoroughly review, print, and fill out these intake forms before your first appointment with Pathway Caring for Children. The Registration Consents and Mental Health Intake Form PDF are to be completed by the parent/guardian for Pathway records and The Privacy Practices are for your records, as the parent/guardian or client.

For questions, please contact our office at 330-493-0083.

All forms may be emailed to

Intake Forms »

To fill out online, please open the PDF in Adobe, navigate to Tools in the upper left, choose ‘fill and sign’. Click for a text box to show up. You may then email the forms back to Pathway.

3CX is Pathway’s HIPAA-compliant video conferencing platform. “Meet” with your Pathway therapist from the comfort and safety of your home.

Privacy Statement


In compliance with HIPAA: Health Insurance Portability and Accountability Act of 1996



Each time you/your child sees a Pathway Caring for Children staff person a record of the visit/contact may be made. Typically, this record contains symptoms, diagnosis, treatment and a plan for future care or treatment. This information, often referred to as the case record, serves as a basis for planning care and treatment. Individually identifiable information about you/your child’s past, present, or future health, the provision of health care to you/your child, or payment for health care is considered “Protected Health Information” (“PHI”). We are required to provide certain protections to you/your child’s PHI, and to give you this Notice about our privacy practices that explain how, when, and why we may use or disclose your/ your child’s PHI. Except in specified circumstances, we must use or disclose only the minimum necessary PHI to accomplish the purpose of the use or disclosure. We are required to follow the privacy practices described in this Notice; though we reserve the right to change our privacy practices and the terms of this Notice at any time. If we do so, you may request a copy of the new notice from our Privacy Officer at the address, Phone number or E-Mail address noted in the last section of this Notice.


For treatment: We may disclose your/your child’s PHI to therapists, school personnel, doctors, Juvenile Court staff and other treatment team members, as applicable, who are involved in providing your/your child’s health/mental health care.

To obtain payment: We may use/disclose your/your child’s PHI in order to bill and collect payment for your health/mental health care services. For example, we may release portions of your/your child’s PHI to your County Department of Job and Family Services, to Medicaid, to ODMH, and/or a private insurer to get paid for services that we delivered to you.

For health care operations: We may use/disclose /your child’s PHI in the course of operating our Pathway foster care services. Or for example, we may use your/your child’s PHI in evaluating the quality of services provided, or disclose your/your child’s PHI to our accountant or attorney for audit purposes. Regulatory and accrediting organizations may review your case record to ensure compliance with their requirements.

USES AND DISCLOSURES OF YOUR/YOUR CHILD’S PHI NOT REQUIRING YOUR CONSENT: The law provides we may use/disclose your/your child’s PHI without consent in the following circumstances:

When required by law: We may disclose PHI when a law requires that we report information about suspected abuse or neglect, or related to suspected criminal activity, or in response to a court order. We must also disclose PHI to authorities that monitor compliance with these privacy requirements.

For health oversight activities: We may disclose PHI to ODJFS, ODMH, MRDD, COA that are agencies responsible for monitoring the foster care system for such activities as licensures, accreditations, audits and reporting or investigating unusual incidents.

USES AND DISCLOSURES REQUIRING YOU TO HAVE AN OPPORTUNITY TO OBJECT: In the following situations we may disclose your/your child’s PHI if we inform you about the disclosure in advance and you do not object. However if there is an emergency situation and you cannot be given the opportunity to object, disclosure may be made if it is consistent with any prior expressed wishes and disclosure is determined to be in your best interests. You must be informed and given an opportunity to object to further disclosure as soon as you are able to do so.

Pathway Directories: Your child’s name, Date of Birth, Date of Placement, Address of your child’s Foster Caregiver will be shared with staff that require this information to perform their job duties.

To family, friends or others involved in your care: We may share with these people information related to your/your child’s family, friends, or other person’s involvement in your/your child’s care.

YOUR RIGHTS REGARDING YOUR/YOUR CHILD’S PHI: You have the following rights relating to your protected health information:

To request restrictions on uses/disclosures: You have the right to ask that we limit how we use or disclose your/your child’s PHI. We will consider your request, but are not legally bound to agree to the restriction. To the extent that we do agree to any restrictions on our use/disclosure of your/your child’s PHI, we will put the agreement in writing in a Release of Information and abide by it except in emergency situations. We cannot agree to limit uses/disclosures that are required by law. Any restrictions on uses or disclosures that you choose to make become a part of your/your child’s file.

To choose how we contact you: You have the right to ask that we send you information at an alternative address or by an alternative means. We must agree to your request as long as it is reasonably easy for us to do so. You have the right to an electronic copy of your file. You also have the right to designate a third party to received electronic copies of electronic PHI.

To inspect and copy your/your child’s PHI: Unless your access is restricted for clear and documented treatment reasons, you have a right to see your/your child’s protected health information if you put your request in writing. We will respond to your request within 30 days. If we deny your access, we will give you written reasons for the denial and explain any right to have the denial reviewed. If you want copies of your/your child’s PHI, a charge for copying may be imposed, but may be waived, depending on your circumstances. You have a right to choose what portions of your information you want copied and to have prior information on the cost of copying.

To request amendment of your/your child’s PHI: If you believe that there is a mistake or missing information in our record of your/your child’s PHI, you may request, in writing, that we correct or add to the record. We will respond within 60 days of receiving your request. We may deny the request if we determine that the PHI is: (1) correct and complete; (2) not created by us and/or not part of our records, or; (3) not permitted to be disclosed. Any denial will state the reasons for denial and explain your rights to have the request and denial, along with any statement in response that you provide, appended to your/your child’s PHI. If we approve the request for amendment, we will change the PHI and so inform you, and tell others that need to know about the change in the PHI.

To find out what disclosures have been made: You have a right to get a list of when, to whom, for what purpose, and what content of your child’s PHI has been released other than instances of disclosure for which you gave consent (i.e. for treatment, payment, operations, to you, your family, or the agency directory). The list also will not include any disclosures made for national security purposes, to law enforcement officials or correctional facilities, or before April 2003. We will respond to your written request for such a list within 60 days of receiving it. Your request can relate to disclosures going as far back as six years. There will be no charge for up to one such list each year. There may be a charge for more frequent requests.

To disclosure restrictions when paid in full—out of pocket only: You have the right to restrict any disclosure of your PHI and payment records to associated payment centers, such as Medicaid and private insurance when you pay your bill, out-of-pocket, in full.

To be notified in case of breach: It is impossible to prevent a breach by 100%. However, Pathway limits access to your/your child’s PHI to only those who need to know and has other protective measures in place to protect against a breach. Should a breach occur, Pathway will notify you as soon as possible and no later than 30 days that a breach has occurred.

To receive this notice: You have a right to receive a paper copy of this Notice and/or an electronic copy by email upon request.

USE OF PHI IN GRANT PROPOSALS: Pathway does not use personal identifiable PHI for any grant proposal. If client information is requested as part of the grant proposal, Pathway provides aggregated and unidentifiable information in the proposal. No names, addresses, social security numbers, or any other personal medical identification is ever included.

PROHIBITION OF SALE OF PHI: Pathway will not share or sell your/your child’s PHI to any vendor of any type, including medical, pharmaceutical, wellness, mental health offices, organizations, or companies.


If you think we may have violated your privacy rights, or you disagree with a decision we made about access to your/your child’s PHI, you may file a complaint with our Privacy Officer at Pathway Caring for Children, 4895 Dressler Rd. NW, Canton, Oh 44718, Phone Number 330 493-0083. You also may file a written complaint with the U.S. Department of Health and Human Services. We will take no incriminating, threatening, coercive, retaliatory, or discriminatory action against you if you make such complaints.