The Resilience Initiative Program Application

The Resilience Initiative is committed to protecting the rights of all families participating in the program. As a participant, you have the following rights: The right for your child/ward to participate in workshops and provide feedback to staff and administration. The right to refuse participation in evaluation tools and to terminate services at any time. The right to confidentiality of records and access to your own records upon request. This program is voluntary, and all staff are mandated reporters under ARS-13-3620. Your child/ward has a right to privacy, and any identifiable information will remain confidential to the fullest extent allowed by state and federal law. However, if staff reasonably believe that your child/ward is in danger, we will involve you whenever possible. We recognize that, in many situations, families play a crucial role in ensuring a child’s safety and well-being. If there is reasonable suspicion that your child is a victim of abuse, physical injury, a reportable offense, or neglect—or if there is a concern for the safety of your child or others—a report may be made to law enforcement and/or the Department of Child Safety (DCS).

As part of our commitment to youth empowerment, we also offer a Youth Leadership Program designed to develop the next generation of confident, compassionate leaders. Through mentorship, team-building exercises, and real-world problem-solving, participants gain invaluable experience in decision-making, communication, and leadership. This program nurtures a sense of responsibility, initiative, and purpose, ensuring that young leaders are prepared to inspire and create positive change in their communities.

1.  By signing this form, a. I/We have read or have had read to me/us Child & Family Resources, Inc.’s statement of policy describing my/our rights and responsibilities as a Client of the agency. I/We understand my/our rights and agree to carry out my/our responsibilities. I/We have received a copy of the Client Rights and Responsibilities statement, as well as a copy of the Child& Family Resources, Inc. Client Grievance Procedure. b. I/we give consent to Child & Family Resources, Inc.to provide services for my child.  

2. Child & Family Resources, Inc. and members of the medial occasionally create slides, photographs and/or video tapes of the different programs CFR offers to children, parents, families and/or childcare providers in the community. These materials are used to inform others about the services that Child & Family Resources, Inc. provides as well as to inform potential funding groups. These materials may also be included in any/all of Child & Family Resources publications and in the local media. Your or your child’s likeness, voice or artwork will only be used with your informed consent.

By signing this form, I state that I have read and understood the information provided to me. I have been given the opportunity to discuss this information with study staff and have my questions answered, and that I agree to have my child take part in this study. I understand that if I choose to provide my child’s email address that Child & Family Resources may use it for contact and questionnaire purposes, and that email is not confidential because sending information over the internet is not always secure.I do not give up any of my legal rights by signing this form. I understand that I will be given a copy of this consent form after signing it. I understand that my child taking part in this workshop is voluntary and that I may remove them from the workshop at any time after signing this form without penalty.   

As a Client of Child & Family Resources, Inc., you have the following rights:To be treated with dignity, respect, and consideration.Not to be discriminated against based on race, national origin, religion, gender or gender identity, sexual orientation, age, disability, marital status, diagnosis, or source of payment.To receive service that:a. Supports and respects your individuality, choices, strengths, and abilities.b. Supports your personal liberty and only restricts it according to a court order, by your consent, or as otherwise permitted by regulation.c. Is provided in the least restrictive environment that meets your treatment needs.Not to be prevented or impeded from exercising your civil rights unless a court has deemed you incompetent or unable to exercise a specific right or category of rights.To submit grievances to agency staff and complaints to outside entities, addressed:a. Without constraints or retaliation.b. In a fair, timely, and impartial manner.To seek, speak to, and be assisted by legal counsel of your choice at your expense.To receive assistance from a family member, designated representative, or another individual in understanding, protecting, or exercising these rights.If enrolled by the Department of Health Services or a Regional Behavioral Health Authority as an individual who is seriously mentally ill, to receive assistance from human rights advocates provided by the Department or its designee.To have your information and records kept confidential and released only as permitted under R9-20-211(A)(3) and (B).To privacy in treatment, including the right not to be fingerprinted, photographed, or recorded without consent, except:a. For photographing for identification and administrative purposes, as provided by A.R.S. §36-507(2).b. For clients receiving treatment according to A.R.S. Title 36, Chapter 37.c. For video recordings used for security purposes, maintained only on a temporary basis according to R9-20-602(A)(5).To review or obtain a copy, upon written request, of your service record during the agency’s hours of operation and to enter a statement into your service record.To review the following at the agency or Department of Health Services:a. A.A.C. Title 9, Chapter 20.b. The report of the most recent CFR inspection conducted by the Department.c. A plan of correction in effect as required by the Department.d. The most recent report of review conducted by the Council on Accreditation (COA).e. Any plan of correction in effect as required by COA.To be informed of all fees, if applicable, before receiving a service and of the agency’s refund policies, except for services provided in a crisis situation.To consent to treatment, unless court-ordered, after receiving an explanation of:a. Your condition and the proposed treatment.b. The intended outcome, nature, risks, side effects, and alternatives of the treatment.To be offered or referred for the treatment specified in your treatment plan.To receive a referral if CFR cannot provide a requested or necessary service.To refuse treatment or withdraw consent unless court-ordered or necessary to save your life or physical health.To be free from:a. Abuse, neglect, exploitation, coercion, manipulation, or retaliation.b. Harassment and violence by CFR staff or clients.c. Discharge or transfer for non-treatment-related reasons, except as established in a signed fee agreement.d. Treatment involving the denial of food, sleep, or restroom use.e. Restraint or seclusion used as coercion, discipline, convenience, or retaliation.To participate (or have your legal representative participate) in treatment decisions and the development, review, and revision of your treatment plan.To consent in writing, refuse, or withdraw consent for research or non-professionally recognized treatments.To refuse to acknowledge gratitude to the agency through statements, media, or public speaking.To receive services in a smoke-free facility.CLIENT RESPONSIBILITIESAs a client of CFR, you also have the following responsibilities:Keeping your appointments and providing at least 24 hours' notice for cancellations. You may be charged for missed or late-canceled appointments.Cooperating in the design and implementation of your service plan. Services may be terminated if you fail to comply with your fee agreement or service plan.Participating, as necessary, in services for your children or children in your guardianship.Paying your agreed-upon fees, if applicable.Providing the necessary information for service eligibility and processing.Reporting changes that may affect your fees or client status.Being responsible for any children you bring to CFR—children cannot be left unattended in the waiting area.Giving consent for treatment of yourself and/or minor children at CFR.CLIENT GRIEVANCE PROCEDUREMost concerns can be resolved by speaking directly to the staff member responsible for your care. If unresolved, follow these steps:Submit a written grievance within 90 days of the incident to the Program Director (or the Service Line Vice President if the Program Director is involved). The grievance may be sent via email or postal mail and must include:a. Your name, address, and telephone number.b. The program and location where you receive services.c. The date(s) of the incident.d. Specific details, including the issue, involved staff members, and others present.e. Actions you have taken to resolve or report the issue.f. The resolution you seek from CFR.The Program Director (or Vice President) will review your grievance and respond in writing within ten (10) working days, possibly consulting with CFR’s CEO.a. If satisfied, confirm your resolution in writing.If unsatisfied, you have ten (10) working days to file a written appeal to CFR’s CEO or request a meeting.Upon receipt:a. The CEO will review and respond in writing within 14 working days.b. If a meeting is requested, the CEO will schedule it within 14 working days and respond within 14 working days after the meeting.c. If satisfied, confirm your resolution in writing.If still unsatisfied, or at any time in the process, you may appeal to the program funding source, if available. If no further process exists, the CEO’s decision is final.For questions, funding source details, or CFR contact information, reach out to the Quality Improvement Director at cqi@cfraz.org or (520) 321-3770.