New Client Paperwork

SECTION I: Orientation with Client Rights and Consent to Treatment

Adult & Pediatric Counseling Specialists PLLC’s purpose is to provide a broad range of treatment, prevention and
supportive services to adults, children or families affected by behavioral health problems.

RIGHTS: As a valued client of Adult & Pediatric Counseling Specialists PLLC you have the right to:

Humane and dignified treatment at all times
Respect for personal dignity and the right to privacy
No deprivation of personal, private or civil rights including the right to vote, contract, hold or convey property
Refuse treatment and refuse participation in research projects. Such refusal will not impact your ability to receive future services

RESPONSIBILITIES: Adult & Pediatric Counseling Specialists PLLC has the responsibility to provide an environment that supports your rights. In return, you are responsible for:

Arriving on time for your scheduled activities
Refraining from the influence of alcohol or drugs during our scheduled activities
Displaying appropriate behavior
Participating in developing a treatment plan with your counselor
Meeting with your counselor to review and update your treatment plan
Making arrangements for payment for services
Respecting the property of the counseling office

Client Grievance Procedure Acknowledgement
Adult & Pediatric Counseling Specialists PLLC Text to uphold the rights of all clients at all times while providing the
best clinical treatment possible. However, should a client at any time have a complaint about their care or feel as
though their rights have been violated, they are encouraged to use the following procedures in an effort to resolve the
issue as quickly as possible.

PROCEDURE SUMMARY
If possible, raise the concern directly with your therapist, the care coordinator or the senior therapist. If this isn't
possible or the situation is uncomfortable, contact the Department of Public Health complaint hotline at 800-842-0038
and/or DMHAS, Purpose of the Recovery Community Affairs Client Rights and Grievances at 800-446-7348.

DISCHARGE POLICY
Clients may be discharged for hostile or threatening behavior towards other persons on the property; vandalism;
unauthorized chronic absences and/or lateness; or clinical needs be on the program scope. Discharge planning,
regardless of the reason for discharge, would be offered along with a formal referral as needed.

By signing below, I understand and acknowledge that I have read and understood this consent:

Today's Date

Your E-Signature