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 consumerMy Vocational Job GoalsMy referring needs and expected outcomeMy objectives and expected outcomesThe methods that will be used to meet my vocational goalsHow my progress will be measured for each objectiveMy responsibility and the responsibility of the other people who will help me with my objectivesHow much time I may need to work toward each objectiveNeed for assistive technology and /or reasonable accommodationsAdditional services available at Goodwill to help me complete my obectivesDevelopment of Individual Opportunity PlanHow the plan will be communicated to meHow the plan will be revisedRequirements for continued participation in services
Additional Comments
Case Manager Signature*

Clear
Consumer Signature*

Clear
Date*

MonthDayYear
Date
Select the method that was used to complete form*
Case Manager Name*
Title*
Date*

MonthDayYear
Date
Should be Empty: