Client and Agency Rights and Responsibilities
WOLVERINE HUMAN SERVICES
CLIENT-AGENCY RIGHTS AND RESPONSIBILITIES
(To be discussed by assigned staff person with clients on day of intake or at first meeting for those clients not in residential treatment.)
I, _______________________________, have discussed with _____________________ their rights and responsibilities as a client and the Agency’s rights and responsibilities. The client was provided information about the types of services to be provided.
As a client of Wolverine Human Services, I understand that I have specific rights:
(Check all that are appropriate)
_____ I have a right to be treated with dignity and respect by all Agency staff and will treat Agency staff and property respectfully in return.
_____ I have a right to live in an environment that is not physically, verbally, and emotionally abusive and to be kept safe from harm.
_____ I have a right to adequate food, clothes, and shelter and to be provided with the means to meet these needs.
_____ I have a right to an education and/or opportunities for work, recreation, and play.
_____ I have a right to maintain contact with my family members as long as it is in conjunction with my treatment plan.
_____ I have a right to be involved in my treatment planning process and development of my treatment goals.
_____ I have a right to talk to an assigned staff member about my needs and problems, and to be treated fairly by staff and/or my foster parents if applicable.
_____ I have a right to confidentiality regarding my treatment records and progress except in those instances where disclosure is required by law or legal mandate.
_____ I have a right to file a grievance if I feel I have been denied available services or otherwise treated unfairly by the Agency’s staff. I am aware of how to file a grievance and have received a copy of the client grievance procedure.
_____ I have a right to refuse treatment and to be told the risks and consequences of refusing treatment unless restricted by programmatic requirements or court order.
_____ I have a right to discuss and negotiate treatment alternatives unless restricted by programmatic requirements or court order.
_____ I have a right to obtain information about the program in which I am participating.
_____ I have the right to participate in spiritual and/or religious enrichment activities/observation.
_____ I have received a Resident/Client/Camper Manual.
_____ I have a right to be free from sexual harassment, rape, or any other form of abuse.
As a client, I understand that the Agency has a right to expect certain responsibilities of me while I am receiving services.
(Check all, which are appropriate)
_____ I may be held legally responsible for breaking the law.
_____ I am, to the best of my ability, not to destroy other people’s property, and not hurt myself, other clients, staff, or foster parents. I know that WHS has a zero tolerance for rape, sexual abuse or threats of these violations.
_____ I am to work with my assigned staff and others to achieve agreed upon goals.
_____ I am to respect other client’s rights to treatment and not to interfere with the care and treatment of others.
_____ I am to notify the assigned staff and staff is to notify me if an appointment is to be changed.
_____ I am expected to participate to the best of my abilities in therapeutic activities, and to complete any paperwork necessary to document if I refuse to participate per my right.
_____ I am expected to follow the rules of the program, and I understand that I may lose privileges if I chose not to follow rules. I also understand that the Agency may request that I be removed from the program and/or placed in a more restrictive setting if my behavior consistently interferes with the care or treatment of myself or others.
Client Signature Date
As a representative of Wolverine Human Services, I assisted the client in the completion of this form, and provided explanation to each point in a manner that the client understood.
Staff Signature and Credentials Date
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