Client and 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:

Client 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.

Client Responsibilities:

(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

Revised 11-13-14