CLIENT CONSENT AND RIGHTS
Client Name: _______________________________________ Date: _________________
ADMISSION AND TREATMENT CONSENT Guidelines for acceptance and participation in the program are the same for everyone without regard to race, color, creed, national origin, age, gender, disability, secual orientation, and/or prior treatment history. It is Brave Health’s policy to provide reasonable accommodations to clients with disabilities to ensure their access and opportunity to the same quality and care as other clients without disabilities. The following information has been reviewed with me:
I hereby give voluntary consent to Brave Health and/or appropriate authorized staff to provide necessary treatment for my substance abuse, dependency, or mental health and to admit me into the program. I may revoke my consent for treatment at any time, either verbally or in writing. ________ Client Initials |
CLIENT RIGHTS As a client of Brave Health services, I understand I have rights to:
Client who believe that any of these standards have been violated may file a grievance in writing with their therapist and/or any staff member. The staff will respond to the grievance with a proposed resolution within three (3) working days. Additionally, complaints may be filed with the Florida Department of Children and Families. A client will not be penalized in any way for asserting rights or complaining about any misconduct on the part of Brave Health or its staff. ________ Client Initials |
CLIENT CONDUCT Clients at Brave Health have expectations for their conduct:
________ Client Initials |
FLUID DRUG SCREENING AND BREATHALYZER CONSENT I agree to provide or comply with request made by Brave Health for fluid drug screening and/or breathalyzer screenings.i understand that the results of such screenings will be used in the determination of my treatment needs, Furthermore, I understand that refusal or failure to provide requested sample may result in discharge from the program. ________ Client Initials |
HIV/AIDS EDUCATION, PREVENTION AND TESTING I understand that I will be asked by Brave Health to complete a confidential individual HIV risk screening. I understand that I may be referred to services as appropriate. Understand that confidential HIV testing is provides per Brave Health policy. ________ Client Initials |
ADVANCED DIRECTIVES I understand that if I have an advanced directive, I can submit a copy of the document to my therapist to be incorporated into my medical record. If I wish to develop an advanced directive, i can contact any area Hospice program for assistance. ________ Client Initials |
PROTECTED HEALTH INFORMATION ANALYSIS AND RESEARCH Brave Health continuously works to improve the services and programs being provided. I understand that as part of normal process, Brave Health conducts supervisory quality reviews, risk management reviews, and other quality assurance reviews. I also understand that my data may be gathered and analyzed by Brave Health staff in order to improve services. I understand that any information about me will not be identifiable as my data in any reports or articles published. I understand that reports containing identifiable information about me to any other individual or organization requires my specific written consent. I am here by restricting the disclosure of any Brave Health reports, reviews, audits which contain my personal identifiable information, other than for licensure or accreditation , unless I provide written authorization. ________ Client Initials |
ETHICS AND PROTOCOLS I understand that Brave Health employees operate under a code of ethical standards. These standards provide guidelines for the client/employee relationship, professional behavior, and the protection of the client welfare. I understand Brave Health does not utilize seclusion or restraints (physical or chemical) in its programs. ________ Client Initials |
CLIENT AGREEMENT I hereby give my voluntary consent for treatment. I have received a copy, read and understand the information contained in this document. I agree to abide by the Client Conduct including the drug screen consent and the criteria for involuntary discharge. I understand my client rights and the information pertaining to confidentiality. Further, i understand the section on HIV/AIDS screening and referral. Client Name:______________________________________ Client ID#: ________________ Client Signature: __________________________________ Date: ____________________ Staff Signature and Credentials: _____________________ Date: ____________________ |
Staff Signature and Credentials: _____________________ Date: ____________________ |