Provider Intake Acknowledgement

I understand that I will be working with a Vocational Services Provider, funded by Opportunities for Ohioans with Disabilities (OOD) to help me reach my goal of working in the community and/or maintaining independence. I also understand that my OOD VR Counselor or VR Contractor will continue to be a part of my Team to help me reach my goal.

Iunderstand that I have certain rights and responsibilities while I am working with my Provider.

My Rights: To be treated fairly and with respect; To be involved in decisions about the services I receive; To bring others to appointments with my Provider (Release of Information may be required; To discuss disagreements about services that I receive with my Provider; To change Providers (Needs to be discussed with my OOD VR Counselor or VR Contractor); and To confidentiality except to report to OOD and under certain situations or risk, such as abuse/neglect or if I may be at risk to harm myself or others.

My Responsibilities: To attend and participate in meetings with my Provider as scheduled; Staying in touch with my Provider via telephone calls and/or emails as agreed upon; and To be an active participant during services like completing assignments, contributing to discussions, asking questions, and more.

If I feel that a Provider is not respecting my rights, the first step should be to discuss the concern with my Provider Staff's Supervisor. If I still do not believe that the issue is resolved, I should contact my

OOD VR Counselor or VR Contractor.

By signing below I acknowledge that my Provider has reviewed my rights and responsibilities and has reviewed the Referral for Services with me and that I will receive a copy of this signed acknowledgement for my records.