As our valued client, you are entitled to:
Have your rights explained in a way that is understandable to you, prior to the initiation of services,
annually, and available for review and clarification at all times that you are enrolled as a client of
The right to confidentiality of your records and information.
The right to be free from mental, physical, sexual or verbal abuse, exploitation, retaliation,
humiliation and neglect.
High quality professional services in a cooperative environment
Receive services in a non-coercive environment
Consultation with your assigned JF&CS staff member to discuss the care you or your loved on are
Request another JF&CS staff member or referral
Be informed of the consequences of non-compliance with agency recommendations and
Know how to lodge complaints, grievances or appeals
Determine disclosure of confidential information as long as such disclosure is not life-threatening or
dangerous to others
Know that your records are protected against unauthorized access and that they can be shared
with others only with your legal consent
Your comments are welcomed:
You may discuss any issues, concerns or questions with your JF&CS staff member
You may request an appointment with your JF&CS staff member's supervisor
You may submit concerns in writing to the Department Head
You may register a complaint by filing a grievance. To file a grievance or receive a copy with
instructions about how to file a grievance please contact Kathy Ray at
or by phone
Actively participate in your own treatment/service and work to achieve your goals.
Keep your scheduled appointments. We ask that client's please cancel appointments with JF&CS staff with 24 hours' notice when possible. If cancellation becomes an issue the assigned JF&CS staff member will address this concern with the client and/or that client's personal representative.
Provide accurate insurance information and benefits coverage. Inform your JF&CS staff member of any significant changes in your financial situation, insurance coverage and/or address.
If applicable, pay the agreed upon fee at the time of service, and be responsible for any outstanding balance to be paid within 30 days of a JF&CS staff member requesting payment for services. The agency reserves the right to suspend or terminate treatment if payment has not been collected within 30 days of request from a JF&CS staff member. This form has been fully explained to me and I certify that I understand its contents. I also understand that it is my sole responsibility to ask any questions or obtain any clarification necessary to my understanding this form fully.