Participant Involvement and Informed Choice

Industries of Wayne and Holmes Counties, Inc.gaoduill

Participant Involvement & Choice (Informed Consent)
Consumer Name *
I was informed of the following (check all) *

My rights as a consumer My Vocational Job Goals My referring needs and expected outcome My objectives and expected outcomes The methods that will be used to meet my vocational goals How my progress will be measured for each objective My responsibility and the responsibility of the other people who will help me with my objectives How much time I may need to work toward each objective Need for assistive technology and /or reasonable accommodations Additional services available at Goodwill to help me complete my obectives Development of Individual Opportunity Plan How the plan will be communicated to me How the plan will be revised Requirements for continued participation in services
Additional Comments
Case Manager Signature *

Clear
Consumer Signature *

Clear
Date *

Month Day Year
Date
Select the method that was used to complete form *
Case Manager Name *
Title *
Date *

Month Day Year
Date
Should be Empty: